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NPI Code Detail

MEDICARE: JENNIFER MAE MANTILLA BSN, RN

MEDICARE: JENNIFER MAE MANTILLA BSN, RN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163W00000XRegistered Nurse981475TX

General Provider Information

NPI Number : 1437783057
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER MAE MANTILLA BSN, RN
Provider Business Mailing Address
First Line : 3053 SAN MARCOS DR
Second Line :
City : FORT WORTH
State : TX
Zip : 76116-4830
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3053 SAN MARCOS DR
Second Line :
City : FORT WORTH
State : TX
Zip : 76116-4830
Country : US
Telephone Number : 817-637-8019
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/24/2020
Last Update Date : 02/24/2020

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