Provider Demographics
NPI:1053517250
Name:MANGINO, MARIE WHITMAN (CRNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:WHITMAN
Last Name:MANGINO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:ERDENHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:19038-1846
Mailing Address - Country:US
Mailing Address - Phone:215-233-5058
Mailing Address - Fax:215-233-1282
Practice Address - Street 1:851 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:ERDENHEIM
Practice Address - State:PA
Practice Address - Zip Code:19038-1846
Practice Address - Country:US
Practice Address - Phone:215-233-5058
Practice Address - Fax:215-233-1282
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP001552H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA059874Medicare ID - Type Unspecified
PAS60732Medicare UPIN