Provider Demographics
NPI:1629570825
Name:MENGOT, PETRINE MANYI
Entity Type:Individual
Prefix:
First Name:PETRINE
Middle Name:MANYI
Last Name:MENGOT
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 1:5700 N KNOLL APT 310
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2253
Mailing Address - Country:US
Mailing Address - Phone:832-207-1411
Mailing Address - Fax:
Practice Address - Street 1:5700 N KNOLL APT 310
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-2253
Practice Address - Country:US
Practice Address - Phone:832-207-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308956164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse