Provider Demographics
NPI:1497015283
Name:MANGWA, ADELINE T (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:T
Last Name:MANGWA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12912 CONAMAR DR UNIT 1931
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-7505
Mailing Address - Country:US
Mailing Address - Phone:240-898-7692
Mailing Address - Fax:
Practice Address - Street 1:10440 LITTLE PATUXENT PKWY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3648
Practice Address - Country:US
Practice Address - Phone:240-203-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MDR230111363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1497015283Medicaid