Provider Demographics
NPI:1659313336
Name:MANCUELLO, MINDI LYN (PA)
Entity Type:Individual
Prefix:MRS
First Name:MINDI
Middle Name:LYN
Last Name:MANCUELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:LYN
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:757-668-7874
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:2025 GLENN MITCHELL DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456
Practice Address - Country:US
Practice Address - Phone:757-507-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104369363A00000X
CT001618363AM0700X
VA0110004770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA182517415AMedicaid
FL2929279-00Medicaid
GA182517415AMedicaid
FLAH085ZMedicare PIN
CTQ43450Medicare UPIN