Provider Demographics
NPI:1255888251
Name:LONGORIA, MANDI (RNC-OB, IBCLC)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:LONGORIA
Suffix:
Gender:F
Credentials:RNC-OB, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MALLARD RUN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 MALLARD RUN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5053
Practice Address - Country:US
Practice Address - Phone:817-538-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-88319163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant