Provider Demographics
NPI:1407975196
Name:MANGELOS, MARILYN KAY (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:KAY
Last Name:MANGELOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-2656
Mailing Address - Country:US
Mailing Address - Phone:209-599-4917
Mailing Address - Fax:209-599-9275
Practice Address - Street 1:838 COBBLESTONE CT
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2656
Practice Address - Country:US
Practice Address - Phone:209-599-4917
Practice Address - Fax:209-599-9275
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN258880163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS005060OtherMEDICAL PROVIDER NUMBER