Provider Demographics
NPI:1306668066
Name:MANGLE, NICOLE LA'SHAWN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LA'SHAWN
Last Name:MANGLE
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 1:15626 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2446
Mailing Address - Country:US
Mailing Address - Phone:216-598-1518
Mailing Address - Fax:
Practice Address - Street 1:15626 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2446
Practice Address - Country:US
Practice Address - Phone:216-598-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No251E00000XAgenciesHome Health