Provider Demographics
NPI:1104875525
Name:MANGA, MERCY B (NP-C)
Entity type:Individual
Prefix:MRS
First Name:MERCY
Middle Name:B
Last Name:MANGA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:770-962-2400
Practice Address - Street 1:2400 MT. ZION PARKWAY
Practice Address - Street 2:KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:770-603-3649
Practice Address - Fax:770-962-2400
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN100057363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA433023341OtherTRICARE
GA500030757OtherRAILROAD MEDICARE PROV #
GA942031013AMedicaid
GA50BBDSTMedicare ID - Type UnspecifiedGA MEDICARE PROV #
GA433023341OtherTRICARE