Provider Demographics
NPI:1902633399
Name:PORTILLO, ISABEL ARMENTA
Entity type:Individual
Prefix:
First Name:ISABEL
Middle Name:ARMENTA
Last Name:PORTILLO
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 1:5768 BLOSSOM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3207
Mailing Address - Country:US
Mailing Address - Phone:408-781-7907
Mailing Address - Fax:
Practice Address - Street 1:2601 S WOOD BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6914
Practice Address - Country:US
Practice Address - Phone:408-781-7907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-1001302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer