Provider Demographics
NPI:1467583492
Name:MANGRUM, BRANDI NICHOLE (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICHOLE
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 PALACE CT
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-9290
Mailing Address - Country:US
Mailing Address - Phone:615-927-7032
Mailing Address - Fax:
Practice Address - Street 1:1776 DECLARATION WAY
Practice Address - Street 2:
Practice Address - City:THOMPSONS STATION
Practice Address - State:TN
Practice Address - Zip Code:37179-9674
Practice Address - Country:US
Practice Address - Phone:615-417-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer