Provider Demographics
NPI:1679970677
Name:MANGUS, MICHELLE ROSE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ROSE
Last Name:MANGUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 FOX DEN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-9179
Mailing Address - Country:US
Mailing Address - Phone:330-590-0637
Mailing Address - Fax:
Practice Address - Street 1:2012 FOX DEN
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27527-9179
Practice Address - Country:US
Practice Address - Phone:330-590-0637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant