MEDICARE: SARAH DEWEESE MANGRUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	202017	AR

General Provider Information

NPI Number	:	1821696725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH DEWEESE MANGRUM

Provider Business Mailing Address
First Line	:	8900 LUXE MNR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8900 LUXE MNR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6122
Country	:	US
Telephone Number	:	615-390-1276
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	01/31/2024

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Directions to “ SARAH DEWEESE MANGRUM ” Practice Location

Language	Start Address	Practice Location

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