Provider Demographics
NPI:1780947861
Name:MOSTOFI, BLAIR NICOLE (RN)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:NICOLE
Last Name:MOSTOFI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:NICOLE
Other - Last Name:MEASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 S EL MOLINO AVE
Mailing Address - Street 2:UNIT 301
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2583
Mailing Address - Country:US
Mailing Address - Phone:860-519-3234
Mailing Address - Fax:
Practice Address - Street 1:13651 WILLARD ST.
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-375-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4290367500000X
CA0019716386163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse