Provider Demographics
NPI:1760069066
Name:MANCILLA, TREVI ANN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TREVI
Middle Name:ANN
Last Name:MANCILLA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:TREVI
Other - Middle Name:ANN
Other - Last Name:MANCILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7533
Mailing Address - Country:US
Mailing Address - Phone:208-529-6111
Mailing Address - Fax:
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program