Provider Demographics
NPI:1164152690
Name:MANGRUM, LETICIA GAIL
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:GAIL
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-4989
Mailing Address - Country:US
Mailing Address - Phone:270-247-6262
Mailing Address - Fax:270-247-8652
Practice Address - Street 1:1225 PARIS RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-4989
Practice Address - Country:US
Practice Address - Phone:270-247-6262
Practice Address - Fax:270-247-8652
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110148156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician