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General NPI Number Information
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NPI Number | 1679139810
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Entity Type | Individual
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Provider Name | CAMILLE MARRERO MANGUAL PTA
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Gender | Female
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Dates
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Enumeration Date | 05/14/2019
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Last Update Date | 05/14/2019
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Provider Practice Location Address
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Address Line | 2080 E FLAMINGO RD STE 111
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City | LAS VEGAS
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State | NV
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Zip | 89119-5175
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Country | US
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Telephone | 702-737-8820
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Fax |
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Provider Business Mailing Address
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Address Line | 6402 RUSTICATED STONE AVE UNIT 102
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City | HENDERSON
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State | NV
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Zip | 89011-1669
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Country | US
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Telephone | 702-628-6862
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | A-1194
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License Number State | NV
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