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General NPI Number Information
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NPI Number | 1750583886
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Entity Type | Individual
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Provider Name | JACQUELINE S MANGRUM LPN
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Gender | Female
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Dates
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Enumeration Date | 06/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3401 N 67TH AVE
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City | PHOENIX
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State | AZ
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Zip | 85033-4517
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Country | US
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Telephone | 623-691-4085
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Fax |
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Provider Business Mailing Address
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Address Line | 3401 N 67TH AVE
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City | PHOENIX
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State | AZ
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Zip | 85033-4517
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Country | US
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Telephone | 623-691-4085
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LP014022
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License Number State | AZ
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