Provider Demographics
NPI:1477138105
Name:MANGRAM, MAKAYLA FORREST (ATC)
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:FORREST
Last Name:MANGRAM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:MAKAYLA
Other - Middle Name:FORREST
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:5334 BIRCHLAND CT
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-9027
Mailing Address - Country:US
Mailing Address - Phone:678-761-2643
Mailing Address - Fax:
Practice Address - Street 1:3590 BRASELTON HWY STE 102
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1120
Practice Address - Country:US
Practice Address - Phone:770-271-1488
Practice Address - Fax:770-271-1822
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0033032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer