Provider Demographics
NPI:1679095590
Name:LARSEN, RACHAEL A (LM)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:A
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-5758
Mailing Address - Country:US
Mailing Address - Phone:206-941-5774
Mailing Address - Fax:253-404-0801
Practice Address - Street 1:860 S 48TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-5758
Practice Address - Country:US
Practice Address - Phone:206-941-5774
Practice Address - Fax:253-404-0801
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW353176B00000X
WA60922648176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2156269Medicaid