Provider Demographics
NPI:1407278419
Name:MANGUM, ANDREA NICHOLE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:NICHOLE
Last Name:MANGUM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-3511
Mailing Address - Country:US
Mailing Address - Phone:256-297-8877
Mailing Address - Fax:
Practice Address - Street 1:117 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-3511
Practice Address - Country:US
Practice Address - Phone:256-297-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-113363363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily