Provider Demographics
NPI:1518912989
Name:LARGE, ELIZABETH JORDANNA
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JORDANNA
Last Name:LARGE
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 1:197 LOMITA DR
Mailing Address - Street 2:STE B
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941
Mailing Address - Country:US
Mailing Address - Phone:415-939-2504
Mailing Address - Fax:415-389-5424
Practice Address - Street 1:197 LOMITA DR
Practice Address - Street 2:STE B
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-939-2504
Practice Address - Fax:415-389-5424
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND92175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath