Provider Demographics
NPI:1619317336
Name:MANGUM, MARTHA CORINNA (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:CORINNA
Last Name:MANGUM
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 HARRY HINES BLVD
Mailing Address - Street 2:POB 1, 10TH FLOOR, SUITE HP10.110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-8879
Mailing Address - Country:US
Mailing Address - Phone:214-645-7700
Mailing Address - Fax:
Practice Address - Street 1:5959 HARRY HINES BLVD
Practice Address - Street 2:POB 1, 10TH FLOOR, SUITE HP10.110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-8879
Practice Address - Country:US
Practice Address - Phone:214-645-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704258437363LA2100X
TXAP131259363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care