Provider Demographics
NPI:1639239668
Name:MANGADA, KRISTIN LOUISE
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LOUISE
Last Name:MANGADA
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 1:89 WALTHAM ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1327
Mailing Address - Country:US
Mailing Address - Phone:914-439-3859
Mailing Address - Fax:
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:D315
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-3796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246649363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner