Provider Demographics
NPI:1609414515
Name:MANGAN, CATHY ELAINE
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:ELAINE
Last Name:MANGAN
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 1:10550 LINDEN LAKE PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-6495
Mailing Address - Country:US
Mailing Address - Phone:703-369-6677
Mailing Address - Fax:
Practice Address - Street 1:10550 LINDEN LAKE PLZ STE 100
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-6495
Practice Address - Country:US
Practice Address - Phone:703-369-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA002049412164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse