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General NPI Number Information
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NPI Number | 1366702870
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Entity Type | Individual
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Provider Name | CRYSTAL VAUGHN MANSE M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/18/2012
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 3 SAINT ELIZABETH BLVD STE 4000
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City | O FALLON
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State | IL
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Zip | 62269-1284
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Country | US
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Telephone | 618-233-5480
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Fax | 618-222-4792
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Provider Business Mailing Address
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Address Line | 3 SAINT ELIZABETH BLVD
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City | O FALLON
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State | IL
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Zip | 62269-1281
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Country | US
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Telephone | 618-234-2120
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0101255760
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 036139867
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036139867
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License Number State | IL
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