Provider Demographics
NPI:1487327987
Name:MANGENTE, KRISTINE A (RN)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:MANGENTE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 BOUQUET CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3999
Mailing Address - Country:US
Mailing Address - Phone:951-373-9122
Mailing Address - Fax:
Practice Address - Street 1:995 BOUQUET CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3999
Practice Address - Country:US
Practice Address - Phone:951-373-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA724086163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherKAISER