Provider Demographics
NPI:1134019326
Name:MANTZOURANIS, LATICIA
Entity type:Individual
Prefix:
First Name:LATICIA
Middle Name:
Last Name:MANTZOURANIS
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 1:175 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4809
Mailing Address - Country:US
Mailing Address - Phone:209-536-2081
Mailing Address - Fax:
Practice Address - Street 1:175 FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4809
Practice Address - Country:US
Practice Address - Phone:209-536-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE0AE3D01D2171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach