Provider Demographics
NPI:1285017608
Name:NANGLE, JENNIN MARY
Entity Type:Individual
Prefix:
First Name:JENNIN
Middle Name:MARY
Last Name:NANGLE
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 1:15 BORMAN CT
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1982
Mailing Address - Country:US
Mailing Address - Phone:631-484-2020
Mailing Address - Fax:
Practice Address - Street 1:15 BORMAN CT
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-1982
Practice Address - Country:US
Practice Address - Phone:631-484-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist