Provider Demographics
NPI:1669183463
Name:MANTILLA, SOLEIMA DALLANA (NP)
Entity type:Individual
Prefix:
First Name:SOLEIMA
Middle Name:DALLANA
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MATLOCK RD STE 804
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4455
Mailing Address - Country:US
Mailing Address - Phone:682-800-3211
Mailing Address - Fax:
Practice Address - Street 1:1900 MATLOCK RD STE 804
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4455
Practice Address - Country:US
Practice Address - Phone:682-800-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1093926363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45220OtherTEXAS BOARD OF NURSING