Provider Demographics
NPI:1043330236
Name:MANGO, MARY (ANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MANGO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 POND VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5200
Mailing Address - Country:US
Mailing Address - Phone:631-291-1876
Mailing Address - Fax:
Practice Address - Street 1:220 N BELLE MEAD RD STE A
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3458
Practice Address - Country:US
Practice Address - Phone:631-941-2273
Practice Address - Fax:631-941-3090
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304256-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health