Provider Demographics
NPI:1972092781
Name:MAZZOCCO, LISA NICOLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:NICOLE
Last Name:MAZZOCCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:NICOLE
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13423 OCEAN GATE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5611
Mailing Address - Country:US
Mailing Address - Phone:310-643-8117
Mailing Address - Fax:
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:310-517-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008622363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care