Provider Demographics
NPI:1003374190
Name:PORTILLO, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13568 COUNTY ROAD 2241
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6616
Mailing Address - Country:US
Mailing Address - Phone:903-805-3123
Mailing Address - Fax:
Practice Address - Street 1:13568 COUNTY ROAD 2241
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-6616
Practice Address - Country:US
Practice Address - Phone:903-805-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant