Provider Demographics
NPI:1619567948
Name:MANCILLA, AMANDA MICHELLE
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MICHELLE
Last Name:MANCILLA
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 1:14220 BECKNER ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2604
Mailing Address - Country:US
Mailing Address - Phone:626-483-9555
Mailing Address - Fax:
Practice Address - Street 1:15330 AMAR RD
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2001
Practice Address - Country:US
Practice Address - Phone:626-961-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34761152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist