Provider Demographics
NPI:1679189708
Name:MANGOH, VALERY A
Entity type:Individual
Prefix:
First Name:VALERY
Middle Name:A
Last Name:MANGOH
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 1:5012 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-1617
Mailing Address - Country:US
Mailing Address - Phone:240-917-8767
Mailing Address - Fax:
Practice Address - Street 1:5012 57TH AVE
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-1617
Practice Address - Country:US
Practice Address - Phone:240-917-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00174434Medicaid