Healthcare Provider Details

I. General information

NPI: 1215577689
Provider Name (Legal Business Name): JOCELYNE ELISA MANSILLA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 06/19/2021
Certification Date: 06/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

IV. Provider business mailing address

2222 FOOTHILL BLVD STE E243
LA CANADA CA
91011-1456
US

V. Phone/Fax

Practice location:
  • Phone: 284-320-0213
  • Fax:
Mailing address:
  • Phone: 818-419-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: