Provider Demographics
NPI:1275156564
Name:VILLA, MAYELA
Entity Type:Individual
Prefix:
First Name:MAYELA
Middle Name:
Last Name:VILLA
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 1:2530 AGATE MDWS
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-1463
Mailing Address - Country:US
Mailing Address - Phone:541-538-1085
Mailing Address - Fax:
Practice Address - Street 1:140 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3113
Practice Address - Country:US
Practice Address - Phone:541-774-7902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist