Provider Demographics
NPI:1538688312
Name:MANGANO, ALICIA MIREYA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MIREYA
Last Name:MANGANO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 W DIVISION ST STE 340
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2995
Mailing Address - Country:US
Mailing Address - Phone:773-541-8100
Mailing Address - Fax:773-541-8109
Practice Address - Street 1:2222 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2717
Practice Address - Country:US
Practice Address - Phone:773-541-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016499163WR0006X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant