Provider Demographics
NPI:1053062943
Name:LARSON, WILLIE (CNM)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:LARSON
Suffix:
Gender:
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 RHODES AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1131
Mailing Address - Country:US
Mailing Address - Phone:310-869-0906
Mailing Address - Fax:
Practice Address - Street 1:5901 RHODES AVE
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-1131
Practice Address - Country:US
Practice Address - Phone:310-869-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95229614163W00000X
CA236523367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse