Basic Information
| Provider Information | |||||||||
| NPI: | 1922567023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 N MAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625231208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178755555 | ||||||||
| FaxNumber: | 2178759640 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N KELLER DR | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173475934 | ||||||||
| FaxNumber: | 2173475939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 3359 | IL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.