Provider Demographics
NPI:1902455470
Name:LARSEN, LOANN KIEULAM
Entity Type:Individual
Prefix:
First Name:LOANN
Middle Name:KIEULAM
Last Name:LARSEN
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 1:822 SANDHILL SAGE ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2952
Mailing Address - Country:US
Mailing Address - Phone:702-525-1739
Mailing Address - Fax:
Practice Address - Street 1:6301 MOUNTAIN VISTA ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2364
Practice Address - Country:US
Practice Address - Phone:702-998-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV822736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics