Healthcare Provider Details

I. General information

NPI: 1780411397
Provider Name (Legal Business Name): SOPHIA AYISHA MAWLAVIZADA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1692 EL CAMINO REAL
SAN CARLOS CA
94070-5208
US

IV. Provider business mailing address

1692 EL CAMINO REAL
SAN CARLOS CA
94070-5208
US

V. Phone/Fax

Practice location:
  • Phone: 650-817-9070
  • Fax: 650-817-9074
Mailing address:
  • Phone: 650-817-9070
  • Fax: 650-817-9074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95233010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: