Provider Demographics
NPI:1710902952
Name:DZATA, MABEL Y (CNM RNP)
Entity Type:Individual
Prefix:
First Name:MABEL
Middle Name:Y
Last Name:DZATA
Suffix:
Gender:F
Credentials:CNM RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2037
Mailing Address - Country:US
Mailing Address - Phone:503-769-9522
Mailing Address - Fax:503-769-9530
Practice Address - Street 1:1373 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-9522
Practice Address - Fax:503-769-9530
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200050056NP NMNP PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000855Medicaid
OR159126Medicare PIN
ORP85473Medicare UPIN