Provider Demographics
NPI:1124569736
Name:MANGUM, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MANGUM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:117 FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-5152
Mailing Address - Country:US
Mailing Address - Phone:828-580-5705
Mailing Address - Fax:828-580-8033
Practice Address - Street 1:117 FOOTHILLS DR
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5152
Practice Address - Country:US
Practice Address - Phone:828-580-5705
Practice Address - Fax:828-580-8033
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5009365363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124569736Medicaid