Healthcare Provider Details

I. General information

NPI: 1043808405
Provider Name (Legal Business Name): MAXINE CERAOLO ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 E 1ST ST
PORT ANGELES WA
98362-4012
US

IV. Provider business mailing address

240 W FRONT ST STE A
PORT ANGELES WA
98362-2609
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-7891
  • Fax: 360-452-8087
Mailing address:
  • Phone: 360-452-7891
  • Fax: 360-452-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61167344
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number417174
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberAP61167344
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: