Provider Demographics
NPI:1801440904
Name:MAZZO, MOLLANDA LAURA (AG-ACNP)
Entity type:Individual
Prefix:
First Name:MOLLANDA
Middle Name:LAURA
Last Name:MAZZO
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N LITCHFIELD RD STE 125
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1228
Mailing Address - Country:US
Mailing Address - Phone:623-242-1231
Mailing Address - Fax:623-242-1232
Practice Address - Street 1:1325 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1228
Practice Address - Country:US
Practice Address - Phone:623-242-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11152363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health