Basic Information
Provider Information | |||||||||
NPI: | 1518050897 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LARSON | ||||||||
FirstName: | QUENLYN | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.N.P. DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10460 FAIRWAY LANE | ||||||||
Address2: |   | ||||||||
City: | CARMEL | ||||||||
State: | CA | ||||||||
PostalCode: | 93923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078268633 | ||||||||
FaxNumber: | 7078268638 | ||||||||
Practice Location | |||||||||
Address1: | 550 E ROMIE LANE | ||||||||
Address2: | SUITE K | ||||||||
City: | SALINAS | ||||||||
State: | CA | ||||||||
PostalCode: | 939014072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314229066 | ||||||||
FaxNumber: | 8314224312 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2006 | ||||||||
LastUpdateDate: | 01/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN-187859 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | NP 19804 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 2350254 | 05 | OH |   | MEDICAID |