Healthcare Provider Details

I. General information

NPI: 1306235049
Provider Name (Legal Business Name): MOBILE HEALTHCARE PROVIDERS NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 SE 177TH AVE
VANCOUVER WA
98683-4201
US

IV. Provider business mailing address

PO BOX 728
CAMAS WA
98607-0728
US

V. Phone/Fax

Practice location:
  • Phone: 360-980-2441
  • Fax: 877-491-4990
Mailing address:
  • Phone: 360-980-2441
  • Fax: 360-831-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY BUCKLAND
Title or Position: OWNER
Credential: APRN, FNP-BC
Phone: 360-773-7463