Provider Demographics
NPI:1215526165
Name:MANTILLA, PENELOPE (SA-C)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 NW 74TH ST APT 2-102
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2400
Mailing Address - Country:US
Mailing Address - Phone:312-672-2209
Mailing Address - Fax:
Practice Address - Street 1:10500 NW 74TH ST APT 2-102
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33178-2400
Practice Address - Country:US
Practice Address - Phone:312-672-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant