Provider Demographics
NPI:1295885242
Name:MANGOONI, JYL A (MBA, ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:JYL
Middle Name:A
Last Name:MANGOONI
Suffix:
Gender:F
Credentials:MBA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 CASCADE CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8083
Mailing Address - Country:US
Mailing Address - Phone:321-961-5593
Mailing Address - Fax:
Practice Address - Street 1:1201 N SCENIC HWY
Practice Address - Street 2:
Practice Address - City:BABSON PARK
Practice Address - State:FL
Practice Address - Zip Code:33827-9751
Practice Address - Country:US
Practice Address - Phone:863-638-2949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 18322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer