Provider Demographics
NPI:1053671099
Name:HANSON, JULIE MANTILLA
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MANTILLA
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:MANTILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:232 6TH AVE
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1250
Mailing Address - Country:US
Mailing Address - Phone:203-687-8146
Mailing Address - Fax:
Practice Address - Street 1:2233 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3045
Practice Address - Country:US
Practice Address - Phone:718-258-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program