MEDICARE: MS. KELLY RENEE MANGOLD CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	2010005602	MO
2	367500000X	Certified Registered Nurse Anesthetist	6708	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477876803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY RENEE MANGOLD CRNA

Provider Business Mailing Address
First Line	:	3 SCARLET OAK CT
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-2130
Country	:	US
Telephone Number	:	312-919-6286
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 SCARLET OAK CT
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-2130
Country	:	US
Telephone Number	:	312-919-6286
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2010
Last Update Date	:	06/28/2023

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