Healthcare Provider Details

I. General information

NPI: 1932013968
Provider Name (Legal Business Name): MAXFIELD LEIF LARSEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 BOGACHIEL WAY
FORKS WA
98331-9120
US

IV. Provider business mailing address

PO BOX 603
FORKS WA
98331-0603
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-5480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number61577930
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: