Basic Information
| Provider Information | |||||||||
| NPI: | 1588966840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCILLA | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | SA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 VISA DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094547348 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 VISA DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094541107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2010 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.