Provider Demographics
NPI:1013286269
Name:MANGANELLO, JENNIFER LIZABETH (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LIZABETH
Last Name:MANGANELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:407 S SCHWARTZ AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-609-6770
Practice Address - Fax:505-609-6775
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0993958-NP363LA2100X
NMCNP-01904363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care