Provider Demographics
NPI:1962604074
Name:MANDENBERG, DEBRA A
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:MANDENBERG
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 1:3089 E LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8582
Mailing Address - Country:US
Mailing Address - Phone:231-929-3646
Mailing Address - Fax:
Practice Address - Street 1:3089 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8582
Practice Address - Country:US
Practice Address - Phone:231-929-3646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704177751163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043802Medicaid
MI0N46840Medicare ID - Type Unspecified