Provider Demographics
NPI:1962648683
Name:MANGAN, MARY C (MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:MANGAN
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4067
Mailing Address - Country:US
Mailing Address - Phone:877-813-5595
Mailing Address - Fax:
Practice Address - Street 1:1500 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-4067
Practice Address - Country:US
Practice Address - Phone:877-813-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP00926363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health