Basic Information
| Provider Information | |||||||||
| NPI: | 1114260650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARLIA-LARSEN | ||||||||
| FirstName: | LORI JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 931 CHEVY WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416903555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 W STEWART AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975013609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416903555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 200942263RN | OR | N | Nursing Service Providers | Registered Nurse | 367A00000X | 201602517NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 201602517NP-PP | 01 | OR | OREGON STATE BOARD OF NURSING | OTHER | 200942263RN | 01 | OR | OSBN | OTHER |