Provider Demographics
NPI:1962370833
Name:MANGIO, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MANGIO
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 1:19933 SPUR HILL DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-1435
Mailing Address - Country:US
Mailing Address - Phone:847-840-2759
Mailing Address - Fax:847-840-2759
Practice Address - Street 1:19933 SPUR HILL DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-1435
Practice Address - Country:US
Practice Address - Phone:847-840-2759
Practice Address - Fax:847-840-2759
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR253879363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health