1619028594 NPI number — FREDDA E MANGEL MA

Table of content: FREDDA E MANGEL MA (NPI 1619028594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619028594 NPI number — FREDDA E MANGEL MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGEL
Provider First Name:
FREDDA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619028594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 ALLEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-773-9722
Provider Business Mailing Address Fax Number:
802-773-9722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 ALLEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-773-9722
Provider Business Practice Location Address Fax Number:
802-773-9722
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  068-0000529 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 356879 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 58100 . This is a "BLUE CROSS-BLUE SHIELD" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1007883 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com