Healthcare Provider Details

I. General information

NPI: 1821576984
Provider Name (Legal Business Name): ELIZABETH MANGANO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS ELIZABETH GILL

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO RD STE 209
RICHMOND VA
23226-1934
US

IV. Provider business mailing address

5875 BREMO RD SOUTH MEDICAL OFFICE BUILDING SUITE 209
RICHMOND VA
23226-1934
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-7804
  • Fax:
Mailing address:
  • Phone: 804-287-7804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001249704
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024176480
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: