Basic Information
| Provider Information | |||||||||
| NPI: | 1144629429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FILLA | ||||||||
| FirstName: | MANDI | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUTSON | ||||||||
| OtherFirstName: | MANDI | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 523 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286681833 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 523 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286681845 | ||||||||
| FaxNumber: | 2896847457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2014 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | COA.16305-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP8073 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.