Provider Demographics
NPI:1326280587
Name:MANGAN, SANDRA KAY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:MANGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21089 SOUTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2242
Mailing Address - Country:US
Mailing Address - Phone:586-598-6947
Mailing Address - Fax:
Practice Address - Street 1:3415 28TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6931
Practice Address - Country:US
Practice Address - Phone:810-987-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704160601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily