Healthcare Provider Details

I. General information

NPI: 1528632031
Provider Name (Legal Business Name): LIZETTE MANGUM-NNAM NJI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 GANNON LN
DALLAS TX
75237-2914
US

IV. Provider business mailing address

3601 HUTCH DR
PLANO TX
75074-8965
US

V. Phone/Fax

Practice location:
  • Phone: 972-283-9090
  • Fax:
Mailing address:
  • Phone: 781-475-4523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1031514
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: