Healthcare Provider Details

I. General information

NPI: 1881675858
Provider Name (Legal Business Name): CLAIRE ELIZABETH MANGUS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 N CAPITOL AVE SITE 500
INDIANAPOLIS IN
46202-1261
US

IV. Provider business mailing address

3401 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-5014
  • Fax: 317-962-2427
Mailing address:
  • Phone: 317-788-9769
  • Fax: 317-781-4868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number72000075A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: