Provider Demographics
NPI:1225413487
Name:MANGAN, TRACY D (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:MANGAN
Suffix:
Gender:F
Credentials:NP
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Other - Last Name:
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Mailing Address - Street 1:10343 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1906
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-739-6167
Practice Address - Street 1:10343 DAWSONS CREEK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1906
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-739-6167
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71005609A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner