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General NPI Number Information
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NPI Number | 1952115743
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Entity Type | Individual
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Provider Name | MAKALA CLINCH MANGRAM PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 02/03/2025
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Last Update Date | 02/03/2025
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Provider Practice Location Address
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Address Line | 700 COASTAL VILLAGE DR
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City | BRUNSWICK
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State | GA
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Zip | 31520-1974
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Country | US
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Telephone | 912-230-3047
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Fax |
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Provider Business Mailing Address
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Address Line | 11014 WOODLAND TRL
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City | BRUNSWICK
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State | GA
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Zip | 31525-1283
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Country | US
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Telephone |
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | RN300259
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License Number State | GA
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