Provider Demographics
NPI:1720174352
Name:MANGRU, SUKDAI (CNM)
Entity Type:Individual
Prefix:MRS
First Name:SUKDAI
Middle Name:
Last Name:MANGRU
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 SCOTT ST
Mailing Address - Street 2:UNIT 216
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3901
Mailing Address - Country:US
Mailing Address - Phone:941-205-2666
Mailing Address - Fax:941-205-2665
Practice Address - Street 1:6210 SCOTT ST
Practice Address - Street 2:UNIT 216
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3901
Practice Address - Country:US
Practice Address - Phone:941-205-2666
Practice Address - Fax:941-205-2665
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000890367A00000X
FLARNP2098022367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330128Medicare ID - Type Unspecified