Provider Demographics
NPI:1033826896
Name:MAZZOLA, MICHAEL BRANDON (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRANDON
Last Name:MAZZOLA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24541 RUTHERFORD RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4029
Mailing Address - Country:US
Mailing Address - Phone:760-315-3072
Mailing Address - Fax:
Practice Address - Street 1:24541 RUTHERFORD RD
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-4029
Practice Address - Country:US
Practice Address - Phone:760-315-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95293225163W00000X
CA564625163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse