Basic Information
| Provider Information | |||||||||
| NPI: | 1699805861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 KATLIAN ST STE E | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077475861 | ||||||||
| FaxNumber: | 9077475415 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 KATLIAN ST STE E | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077475861 | ||||||||
| FaxNumber: | 9077475415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 85 | AK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT34621 | 05 | AK | MEDICAID |