Provider Demographics
NPI:1346929809
Name:MANGA, NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MANGA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1778
Mailing Address - Country:US
Mailing Address - Phone:248-881-4513
Mailing Address - Fax:
Practice Address - Street 1:35640 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2981
Practice Address - Country:US
Practice Address - Phone:734-793-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist