Healthcare Provider Details

I. General information

NPI: 1063862605
Provider Name (Legal Business Name): MASHA MOBBLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA ALEXANDROVNA NAZOROVA

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15906 MILL CREEK BLVD
MILL CREEK WA
98012-1797
US

IV. Provider business mailing address

PO BOX 24325
SEATTLE WA
98124-0325
US

V. Phone/Fax

Practice location:
  • Phone: 425-385-2009
  • Fax:
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP8761
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61090484
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: