Provider Demographics
NPI:1144272873
Name:GANGL PEREZ, NICOLE MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:GANGL PEREZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 OAK MANOR DR STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5553
Mailing Address - Country:US
Mailing Address - Phone:410-766-4878
Mailing Address - Fax:
Practice Address - Street 1:331 OAK MANOR DR STE 101
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5553
Practice Address - Country:US
Practice Address - Phone:410-766-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN649470000Medicaid