Provider Demographics
NPI:1053662635
Name:MANGANIELLO, KRISTA MARIE (MS, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:MANGANIELLO
Suffix:
Gender:F
Credentials:MS, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 SW GOSSAMER CIR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-1554
Mailing Address - Country:US
Mailing Address - Phone:772-285-5401
Mailing Address - Fax:
Practice Address - Street 1:4729 SW GOSSAMER CIR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1554
Practice Address - Country:US
Practice Address - Phone:772-285-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 14450235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist