Basic Information
| Provider Information | |||||||||
| NPI: | 1003840455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGEL | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 NEUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285603449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526338640 | ||||||||
| FaxNumber: | 2526365376 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 NEUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285603449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526338640 | ||||||||
| FaxNumber: | 2526365376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 128402 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8052384 | 05 | NC | MEDICAID | 014MR | 01 | NC | BCBS GROUP BILLING # | OTHER | 8000311 | 05 | NC | MEDICAID |