Basic Information
| Provider Information | |||||||||
| NPI: | 1104875525 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MANGA | ||||||||
| FirstName: | MERCY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045045678 | ||||||||
| FaxNumber: | 7709622400 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 MT. ZION PARKWAY | ||||||||
| Address2: | KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706033649 | ||||||||
| FaxNumber: | 7709622400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | RN100057 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 433023341 | 01 | GA | TRICARE | OTHER | 500030757 | 01 | GA | RAILROAD MEDICARE PROV # | OTHER | 942031013A | 05 | GA | MEDICAID |