Provider Demographics
NPI:1982167284
Name:LARSON, JODY MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-8137
Mailing Address - Country:US
Mailing Address - Phone:715-325-2276
Mailing Address - Fax:
Practice Address - Street 1:3741 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-8137
Practice Address - Country:US
Practice Address - Phone:715-325-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI150029030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health