Provider Demographics
NPI:1669181558
Name:LARSON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19772 160TH ST N
Mailing Address - Street 2:
Mailing Address - City:BORUP
Mailing Address - State:MN
Mailing Address - Zip Code:56519-9660
Mailing Address - Country:US
Mailing Address - Phone:701-541-7220
Mailing Address - Fax:
Practice Address - Street 1:19772 160TH ST N
Practice Address - Street 2:
Practice Address - City:BORUP
Practice Address - State:MN
Practice Address - Zip Code:56519-9660
Practice Address - Country:US
Practice Address - Phone:701-541-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1112157253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency