Provider Demographics
NPI:1821680356
Name:MANTILLA, ANNY JOHANNA (LMT)
Entity Type:Individual
Prefix:
First Name:ANNY
Middle Name:JOHANNA
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 THOMAS JOHNSON DR STE 8
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4442
Mailing Address - Country:US
Mailing Address - Phone:301-732-3304
Mailing Address - Fax:
Practice Address - Street 1:198 THOMAS JOHNSON DR STE 8
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4442
Practice Address - Country:US
Practice Address - Phone:301-732-3304
Practice Address - Fax:301-228-3904
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist