Provider Demographics
NPI:1407924384
Name:MANGUM, CANDACE D (CRNP)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:D
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:NOTASULGA
Mailing Address - State:AL
Mailing Address - Zip Code:36866-0100
Mailing Address - Country:US
Mailing Address - Phone:334-257-1081
Mailing Address - Fax:334-257-1086
Practice Address - Street 1:56 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NOTASULGA
Practice Address - State:AL
Practice Address - Zip Code:36866-0100
Practice Address - Country:US
Practice Address - Phone:334-257-1081
Practice Address - Fax:334-257-1086
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-090975363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164550489OtherORGANIZATIONAL NPI
AL891017112Medicaid
AL051558482OtherPTAN
AL051558482OtherPTAN
AL891017112Medicaid