Healthcare Provider Details

I. General information

NPI: 1538688312
Provider Name (Legal Business Name): ALICIA MIREYA MANGANO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W DIVISION ST
CHICAGO IL
60622-2717
US

IV. Provider business mailing address

2222 W DIVISION ST STE 340
CHICAGO IL
60622-2995
US

V. Phone/Fax

Practice location:
  • Phone: 773-541-8100
  • Fax:
Mailing address:
  • Phone: 773-541-8100
  • Fax: 773-541-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number209.016499
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: