Provider Demographics
NPI:1114226628
Name:MORTAZAVI, BEHNOUSH (NP-C, MSN)
Entity Type:Individual
Prefix:MRS
First Name:BEHNOUSH
Middle Name:
Last Name:MORTAZAVI
Suffix:
Gender:F
Credentials:NP-C, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3320
Mailing Address - Country:US
Mailing Address - Phone:213-284-3200
Mailing Address - Fax:213-284-3352
Practice Address - Street 1:400 W 30TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3320
Practice Address - Country:US
Practice Address - Phone:213-284-3200
Practice Address - Fax:213-284-3352
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV001263363LX0001X
CA202470363LF0000X
CA20470363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20470OtherNP LICENSE