Healthcare Provider Details

I. General information

NPI: 1710589585
Provider Name (Legal Business Name): NICOLE ANN MANGETT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4154 W VIENNA RD
CLIO MI
48420-2809
US

IV. Provider business mailing address

225 E 5TH ST
FLINT MI
48502-1641
US

V. Phone/Fax

Practice location:
  • Phone: 810-406-4246
  • Fax:
Mailing address:
  • Phone: 810-406-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704323666
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704323666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: