Provider Demographics
NPI:1215577689
Name:MANSILLA, JOCELYNE ELISA (PA)
Entity Type:Individual
Prefix:
First Name:JOCELYNE
Middle Name:ELISA
Last Name:MANSILLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 FOOTHILL BLVD STE E243
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1456
Mailing Address - Country:US
Mailing Address - Phone:818-419-4278
Mailing Address - Fax:
Practice Address - Street 1:400 W 30TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3320
Practice Address - Country:US
Practice Address - Phone:284-320-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA58341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program