Provider Demographics
NPI:1497474373
Name:TELIDEVARA, MANGA (NP)
Entity Type:Individual
Prefix:MS
First Name:MANGA
Middle Name:
Last Name:TELIDEVARA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 WORSHAM ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-4497
Mailing Address - Country:US
Mailing Address - Phone:281-650-0945
Mailing Address - Fax:
Practice Address - Street 1:615 WORSHAM ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-4497
Practice Address - Country:US
Practice Address - Phone:281-650-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily