Provider Demographics
NPI:1942729355
Name:MUTTILLO, ALEXIS ROSE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ROSE
Last Name:MUTTILLO
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 1:1054 CAMERON CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-0078
Mailing Address - Country:US
Mailing Address - Phone:803-579-9474
Mailing Address - Fax:
Practice Address - Street 1:1054 CAMERON CREEK PKWY
Practice Address - Street 2:
Practice Address - City:TEGA CAY
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-579-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer