Provider Demographics
NPI:1447462635
Name:LARSON, DIANE JEAN (LPN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:JEAN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2273 KOENE CT
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-2719
Mailing Address - Country:US
Mailing Address - Phone:920-467-6803
Mailing Address - Fax:
Practice Address - Street 1:W2273 KOENE CT
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-2719
Practice Address - Country:US
Practice Address - Phone:920-467-6803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20152031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35028400Medicaid