Healthcare Provider Details

I. General information

NPI: 1114226628
Provider Name (Legal Business Name): BEHNOUSH MORTAZAVI NP-C, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

IV. Provider business mailing address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

V. Phone/Fax

Practice location:
  • Phone: 213-284-3200
  • Fax: 213-284-3352
Mailing address:
  • Phone: 213-284-3200
  • Fax: 213-284-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number001263
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202470
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number20470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: