Healthcare Provider Details

I. General information

NPI: 1669917654
Provider Name (Legal Business Name): DEBRA D MANGRUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 203RD ST STE 204
OLYMPIA FIELDS IL
60461-1185
US

IV. Provider business mailing address

35318 EAGLE WAY
CHICAGO IL
60678-1353
US

V. Phone/Fax

Practice location:
  • Phone: 708-852-2641
  • Fax: 708-503-3260
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71007051A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209015375
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: