Basic Information
Provider Information | |||||||||
NPI: | 1770614489 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOSLEY | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TAYLOR | ||||||||
OtherFirstName: | CHERYL | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3120 NE 158TH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972305111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9712695331 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 651 WAKE AVE STE A | ||||||||
Address2: |   | ||||||||
City: | EL CENTRO | ||||||||
State: | CA | ||||||||
PostalCode: | 92243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603522257 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 05/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200650151NP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.