Provider Demographics
NPI:1902792245
Name:NOLASCO, MARY MICHELLE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:NOLASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27464 REDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-5774
Mailing Address - Country:US
Mailing Address - Phone:323-605-2890
Mailing Address - Fax:
Practice Address - Street 1:2275 LAS POSAS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3344
Practice Address - Country:US
Practice Address - Phone:805-388-3732
Practice Address - Fax:805-987-2904
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2025035863363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner