Provider Demographics
NPI:1457166308
Name:MBOLO, MARY (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MBOLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 W AVENUE M2
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2841
Mailing Address - Country:US
Mailing Address - Phone:661-888-3270
Mailing Address - Fax:
Practice Address - Street 1:3130 W AVENUE M2
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-2841
Practice Address - Country:US
Practice Address - Phone:661-888-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA764338163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse