Provider Demographics
NPI:1184982753
Name:MANGRUEN, DONNA MARIE (APN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:MANGRUEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6061
Mailing Address - Country:US
Mailing Address - Phone:815-543-7020
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009325364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health