=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578437471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PNW MOBILE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2025
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8001 SHADYWOOD LN SW
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98498-5425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-201-7044
-----------------------------------------------------
Fax | 719-201-7044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8001 SHADYWOOD LN SW
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98498-5425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-201-7044
-----------------------------------------------------
Fax | 719-201-7044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAISA ROZUL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-201-7044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------