Healthcare Provider Details

I. General information

NPI: 1962988873
Provider Name (Legal Business Name): ROXANA KOREN MANGER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

IV. Provider business mailing address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

V. Phone/Fax

Practice location:
  • Phone: 815-490-1600
  • Fax: 815-490-1881
Mailing address:
  • Phone: 815-490-1600
  • Fax: 815-490-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number16545-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: