Healthcare Provider Details

I. General information

NPI: 1326280587
Provider Name (Legal Business Name): SANDRA KAY MANGAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 28TH ST
PORT HURON MI
48060-6931
US

IV. Provider business mailing address

21089 SOUTHWAY DR
MACOMB MI
48044-2242
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5300
  • Fax:
Mailing address:
  • Phone: 586-598-6947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704160601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: