Healthcare Provider Details

I. General information

NPI: 1407431893
Provider Name (Legal Business Name): ALIYAH MANGRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-6949
  • Fax: 708-684-2675
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007891
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-008132
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: