Provider Demographics
NPI:1467722199
Name:MANGUAL, ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:MANGUAL
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 1:255A S CAMINO DEL PUEBLO
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5973
Mailing Address - Country:US
Mailing Address - Phone:505-867-2356
Mailing Address - Fax:505-867-2357
Practice Address - Street 1:255A S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5973
Practice Address - Country:US
Practice Address - Phone:505-867-2356
Practice Address - Fax:505-867-2357
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01799924003252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency