Provider Demographics
NPI:1841949542
Name:MANGINE, RACHEL GUPTON
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:GUPTON
Last Name:MANGINE
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 1:1420 S BURGANDY TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5443
Mailing Address - Country:US
Mailing Address - Phone:904-657-6849
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR STE 1400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8364
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11028581363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics