Provider Demographics
NPI:1386350007
Name:MANGONES, ROSE GINA
Entity type:Individual
Prefix:
First Name:ROSE GINA
Middle Name:
Last Name:MANGONES
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 1:2608 SERENITY CIR N
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5047
Mailing Address - Country:US
Mailing Address - Phone:772-240-5876
Mailing Address - Fax:
Practice Address - Street 1:2608 SERENITY CIR N
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5047
Practice Address - Country:US
Practice Address - Phone:772-240-5876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF09220783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily