Healthcare Provider Details

I. General information

NPI: 1073953345
Provider Name (Legal Business Name): LAUREN E LARSEN RN-PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

IV. Provider business mailing address

PO BOX 14691
PORTLAND OR
97293-0691
US

V. Phone/Fax

Practice location:
  • Phone: 503-782-8907
  • Fax: 503-386-3310
Mailing address:
  • Phone: 503-782-8907
  • Fax: 503-386-3310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201340303RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201501816NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: