Healthcare Provider Details

I. General information

NPI: 1386570091
Provider Name (Legal Business Name): MARIEL COLLEEN MANTIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 12TH ST
OAKLAND CA
94607-4927
US

IV. Provider business mailing address

3775 FULMAR TER
FREMONT CA
94555-1546
US

V. Phone/Fax

Practice location:
  • Phone: 800-607-6377
  • Fax:
Mailing address:
  • Phone: 408-420-6820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95224817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: