Provider Demographics
NPI:1861252082
Name:LARSON, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:LARSON
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 1:14111 93RD PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8912
Mailing Address - Country:US
Mailing Address - Phone:612-670-2058
Mailing Address - Fax:612-299-1425
Practice Address - Street 1:11204 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4510
Practice Address - Country:US
Practice Address - Phone:612-470-0105
Practice Address - Fax:612-299-1425
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN414944374U00000X, 376J00000X, 376K00000X, 251E00000X
414944385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care