Provider Demographics
NPI:1821565623
Name:MANKOSA, ELISE ANN
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:ANN
Last Name:MANKOSA
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 1:1150 W 24TH ST STE F1
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8368
Mailing Address - Country:US
Mailing Address - Phone:928-248-5557
Mailing Address - Fax:
Practice Address - Street 1:1150 W 24TH ST STE F1
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8368
Practice Address - Country:US
Practice Address - Phone:928-248-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor