Healthcare Provider Details

I. General information

NPI: 1164115010
Provider Name (Legal Business Name): JOANNA MANGOLD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOANNA WILLIS RN

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 WATT AVE BLDG E
SACRAMENTO CA
95821-2640
US

IV. Provider business mailing address

3208 WOEDEE DR
EL DORADO HILLS CA
95762-7502
US

V. Phone/Fax

Practice location:
  • Phone: 916-488-6200
  • Fax: 916-488-6300
Mailing address:
  • Phone: 951-258-0690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: