Healthcare Provider Details

I. General information

NPI: 1144629429
Provider Name (Legal Business Name): MANDI L. FILLA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDI L. HUTSON

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 ROSE LN
WICKENBURG AZ
85390-1448
US

IV. Provider business mailing address

523 ROSE LN
WICKENBURG AZ
85390-1448
US

V. Phone/Fax

Practice location:
  • Phone: 928-668-1845
  • Fax: 289-684-7457
Mailing address:
  • Phone: 928-668-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.16305-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP8073
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: