Provider Demographics
NPI:1013226026
Name:MANGRUM, HEATHER NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:MANGRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:125 CRESTVIEW PARK DR STE 2
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2853
Mailing Address - Country:US
Mailing Address - Phone:615-740-5233
Mailing Address - Fax:615-740-5226
Practice Address - Street 1:125 CRESTVIEW PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2853
Practice Address - Country:US
Practice Address - Phone:615-740-5233
Practice Address - Fax:615-740-5226
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530456Medicaid
TN1530456Medicaid