Provider Demographics
NPI:1881290583
Name:MANDAZA, MAGDALINE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:MAGDALINE
Middle Name:
Last Name:MANDAZA
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MAGDALINE
Other - Middle Name:
Other - Last Name:MANDAZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:WOMACK ARMY MEDICAL CENTER 2817 ROCK MERRITT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 ROCK MERRITT AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN261131880363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61126076OtherMILITARY AND CIVILIAN
WA1881290583OtherPSYCHIATRY
WAAP61126076OtherMILITARY AND CIVILIAN