Provider Demographics
NPI:1528087699
Name:MANTIZIAN, NELLY
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:MANTIZIAN
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 1:2717 W AVENUE L
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-4057
Mailing Address - Country:US
Mailing Address - Phone:661-943-8270
Mailing Address - Fax:661-943-8396
Practice Address - Street 1:2717 W AVENUE L
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-4057
Practice Address - Country:US
Practice Address - Phone:661-943-8270
Practice Address - Fax:661-943-8396
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies