Healthcare Provider Details

I. General information

NPI: 1821874462
Provider Name (Legal Business Name): MIGUEL ANGEL DE LA MORA DNP, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N CENTER PKWY STE 113
KENNEWICK WA
99336-7160
US

IV. Provider business mailing address

1030 N CENTER PKWY STE 113
KENNEWICK WA
99336-7160
US

V. Phone/Fax

Practice location:
  • Phone: 509-910-4559
  • Fax: 509-447-7455
Mailing address:
  • Phone: 509-910-4559
  • Fax: 509-447-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61485710
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: