Healthcare Provider Details

I. General information

NPI: 1619317336
Provider Name (Legal Business Name): MARTHA CORINNA MANGUM ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 HARRY HINES BLVD POB 1, 10TH FLOOR, SUITE HP10.110
DALLAS TX
75390-8879
US

IV. Provider business mailing address

5959 HARRY HINES BLVD POB 1, 10TH FLOOR, SUITE HP10.110
DALLAS TX
75235-8879
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-7700
  • Fax:
Mailing address:
  • Phone: 214-645-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704258437
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP131259
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: