Provider Demographics
NPI:1669638953
Name:MANGANELLO, KELLY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MANGANELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:MANNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:297 SPINDRIFT DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7894
Mailing Address - Country:US
Mailing Address - Phone:716-831-2600
Mailing Address - Fax:716-831-2601
Practice Address - Street 1:297 SPINDRIFT DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7894
Practice Address - Country:US
Practice Address - Phone:716-831-2600
Practice Address - Fax:716-831-2601
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant