Provider Demographics
NPI:1013286269
Name:MANGANELLO, JENNIFER LIZABETH (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LIZABETH
Last Name:MANGANELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LIZABETH
Other - Last Name:VAN HAUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:175 MERCADO ST STE 131
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7318
Mailing Address - Country:US
Mailing Address - Phone:970-382-2000
Mailing Address - Fax:970-382-2069
Practice Address - Street 1:175 MERCADO ST STE 131
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7318
Practice Address - Country:US
Practice Address - Phone:970-382-2000
Practice Address - Fax:970-382-2069
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0993958-NP363LA2100X
NMCNP-01904363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000156015Medicaid