1780117655 NPI number — REBECCA LEIGH MANGANELLO DO

Table of content: REBECCA LEIGH MANGANELLO DO (NPI 1780117655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780117655 NPI number — REBECCA LEIGH MANGANELLO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGANELLO
Provider First Name:
REBECCA
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DRUCKER
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780117655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603949
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-350-0351
Provider Business Mailing Address Fax Number:
919-350-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 ASHVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27518-6676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-9625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2017

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: 207Q00000X , with the licence number:  OS16860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2022-01884 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QB0002X , with the licence number: 2022-01884 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1780117655 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110534800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".