Provider Demographics
NPI:1114407368
Name:PRASAD-MANGAL, MEENAL MANDEETA (LVN)
Entity Type:Individual
Prefix:
First Name:MEENAL
Middle Name:MANDEETA
Last Name:PRASAD-MANGAL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MEENAL
Other - Middle Name:MANDEETA
Other - Last Name:PRASAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:4200 HERITAGE CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8785
Mailing Address - Country:US
Mailing Address - Phone:916-613-6652
Mailing Address - Fax:
Practice Address - Street 1:441 S HAM LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-224-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287331164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse