Provider Demographics
NPI:1194281444
Name:MANJGALADZE, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MANJGALADZE
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 1:600 FISHERS STATION DR STE 117
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9784
Mailing Address - Country:US
Mailing Address - Phone:585-337-0992
Mailing Address - Fax:585-337-0998
Practice Address - Street 1:600 FISHERS STATION DR STE 117
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9784
Practice Address - Country:US
Practice Address - Phone:585-337-0992
Practice Address - Fax:585-337-0998
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001782363L00000X
NY402705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner