Provider Demographics
NPI:1780117655
Name:MANGANELLO, REBECCA LEIGH (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:MANGANELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:DRUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:210 ASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6676
Practice Address - Country:US
Practice Address - Phone:919-350-9625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16860207Q00000X
NC2022-01884207Q00000X, 207QB0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780117655Medicaid