Healthcare Provider Details

I. General information

NPI: 1104786193
Provider Name (Legal Business Name): MIHAELA LEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21610 PACIFIC WAY
OCEAN PARK WA
98640-3206
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-665-3000
  • Fax: 360-665-3096
Mailing address:
  • Phone: 360-261-7848
  • Fax: 360-232-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP70168924
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: