Provider Demographics
NPI:1871245357
Name:MANGLE, MARY GRACE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:MANGLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MAIN ST APT S304
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-0307
Mailing Address - Country:US
Mailing Address - Phone:175-758-0579
Mailing Address - Fax:
Practice Address - Street 1:220 E 42ND ST FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5831
Practice Address - Country:US
Practice Address - Phone:646-416-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1555744363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health