Provider Demographics
NPI:1902404429
Name:MANGERIS, CANDICE LYNN
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYNN
Last Name:MANGERIS
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 1:1462 ROWLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1569
Mailing Address - Country:US
Mailing Address - Phone:330-906-9663
Mailing Address - Fax:
Practice Address - Street 1:1462 ROWLAND AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1569
Practice Address - Country:US
Practice Address - Phone:330-906-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0221626Medicaid