Basic Information
| Provider Information | |||||||||
| NPI: | 1992323604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | CASSONDRA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 3013408339 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 IMPERIAL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217406556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016659098 | ||||||||
| FaxNumber: | 3016659096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | R201221 | MD | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | R201221 | 01 | MD | LICENSE | OTHER | ASC-197Z | 05 | MD | MEDICAID |