Provider Demographics
NPI:1801126446
Name:MANGAN, KELLY ANN (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MANGAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 VALLE DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7849
Mailing Address - Country:US
Mailing Address - Phone:619-888-8862
Mailing Address - Fax:
Practice Address - Street 1:4754 PALM AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5253
Practice Address - Country:US
Practice Address - Phone:619-888-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13142171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist