Healthcare Provider Details

I. General information

NPI: 1467583492
Provider Name (Legal Business Name): BRANDI NICHOLE MANGRUM MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 DECLARATION WAY
THOMPSONS STATION TN
37179-9674
US

IV. Provider business mailing address

2707 PALACE CT
THOMPSONS STATION TN
37179-9290
US

V. Phone/Fax

Practice location:
  • Phone: 615-417-9656
  • Fax:
Mailing address:
  • Phone: 615-927-7032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number812
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: