MEDICARE: MRS. AMY K MANGRUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720603228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY K MANGRUM

Provider Business Mailing Address
First Line	:	1100 NW 9TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-6061
Country	:	US
Telephone Number	:	239-245-4033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 NW 9TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-6061
Country	:	US
Telephone Number	:	123-924-5403
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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Directions to “ MRS. AMY K MANGRUM ” Practice Location

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