Provider Demographics
NPI:1245810217
Name:MAMMENGA, EMILY (MD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MAMMENGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:ATTN: PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:
Practice Address - Street 1:1895 N JASPER DR STE 3
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1632
Practice Address - Country:US
Practice Address - Phone:289-138-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN745592084P0800X
AZ776262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry