Healthcare Provider Details

I. General information

NPI: 1801126446
Provider Name (Legal Business Name): KELLY ANN MANGAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4754 PALM AVE
LA MESA CA
91942-5253
US

IV. Provider business mailing address

4370 VALLE DR
LA MESA CA
91941-7849
US

V. Phone/Fax

Practice location:
  • Phone: 619-888-8862
  • Fax:
Mailing address:
  • Phone: 619-888-8862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: