Provider Demographics
NPI:1609583483
Name:MANGRUM, JULIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BLOCKER LN
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-1458
Mailing Address - Country:US
Mailing Address - Phone:423-368-4752
Mailing Address - Fax:
Practice Address - Street 1:2255 CANDIES LN NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2661
Practice Address - Country:US
Practice Address - Phone:423-472-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5469225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant