Provider Demographics
NPI:1184054371
Name:MANGUAL, AMY B (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:B
Last Name:MANGUAL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1787
Mailing Address - Country:US
Mailing Address - Phone:315-265-2000
Mailing Address - Fax:
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-265-2000
Practice Address - Fax:315-265-5458
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY412073163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool