Provider Demographics
NPI:1629085113
Name:MANNIX-CANTILLON, MARY ELLEN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:MANNIX-CANTILLON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 CLEMENT ST
Mailing Address - Street 2:SFVAMC NEUROSURGERY SERVICE (112)
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1545
Mailing Address - Country:US
Mailing Address - Phone:415-221-4810
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:SFVAMC NEUROSURGERY SERVICE (112)
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336318363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health