Provider Demographics
NPI:1427468370
Name:MANGANARO, CARRIE LYN
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYN
Last Name:MANGANARO
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 1:11 TULIP CT
Mailing Address - Street 2:
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-1901
Mailing Address - Country:US
Mailing Address - Phone:631-655-3818
Mailing Address - Fax:
Practice Address - Street 1:11 TULIP CT
Practice Address - Street 2:
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-1901
Practice Address - Country:US
Practice Address - Phone:631-655-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314519-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse