Provider Demographics
NPI:1538285440
Name:MANDL, ROSE COBELLI (RN)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:COBELLI
Last Name:MANDL
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 1:167 CALKINS RD LOT 4
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-8752
Mailing Address - Country:US
Mailing Address - Phone:607-272-2370
Mailing Address - Fax:
Practice Address - Street 1:167 CALKINS RD LOT 4
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-8752
Practice Address - Country:US
Practice Address - Phone:607-272-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132705-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02771268Medicaid