Healthcare Provider Details

I. General information

NPI: 1689110736
Provider Name (Legal Business Name): EMMA CAROLINE MANGOLD CRNA DNP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. EMMA CAROLINE WEATHERLY

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

PO BOX 1776
SEWARD AK
99664-1776
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118586
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11021077
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: