Provider Demographics
NPI:1679855407
Name:MANGONES, PATRICIA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MANGONES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:54 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5618
Mailing Address - Country:US
Mailing Address - Phone:617-894-6601
Mailing Address - Fax:
Practice Address - Street 1:173 CHELSEA ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-4632
Practice Address - Country:US
Practice Address - Phone:781-388-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1153691041C0700X
MARN2283384363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical