Provider Demographics
NPI:1295569507
Name:MANDIGO, DANIELLE CONSTANCE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:CONSTANCE
Last Name:MANDIGO
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 1:235 LAKEMONT ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855
Mailing Address - Country:US
Mailing Address - Phone:802-624-4016
Mailing Address - Fax:
Practice Address - Street 1:235 LAKEMONT ROAD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855
Practice Address - Country:US
Practice Address - Phone:802-624-4016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist