Healthcare Provider Details

I. General information

NPI: 1972035442
Provider Name (Legal Business Name): MATILDA MANKA MANGAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42756 PORTRAITS LN
TEMECULA CA
92592
US

IV. Provider business mailing address

42756 PORTRAITS LN
TEMECULA CA
92592
US

V. Phone/Fax

Practice location:
  • Phone: 949-351-3238
  • Fax:
Mailing address:
  • Phone: 949-351-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95006288
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberNP95006288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: