Healthcare Provider Details

I. General information

NPI: 1942966312
Provider Name (Legal Business Name): MRS. CHARLENE MANGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WOODRUFF RD STE A3
GREENVILLE SC
29607-5732
US

IV. Provider business mailing address

1200 WOODRUFF RD STE A3
GREENVILLE SC
29607-5732
US

V. Phone/Fax

Practice location:
  • Phone: 864-272-3432
  • Fax: 864-272-3435
Mailing address:
  • Phone: 864-272-3432
  • Fax: 864-272-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number72030
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number72030
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number72030
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: