Provider Demographics
NPI:1417452632
Name:MANCILLA, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MANCILLA
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 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-3124
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE STE 116
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5665
Practice Address - Country:US
Practice Address - Phone:602-933-1010
Practice Address - Fax:602-933-5395
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD94210208000000X
390200000X
AZ70186208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ187918Medicaid