Provider Demographics
NPI:1720603228
Name:MANGRUM, AMY K
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:K
Last Name:MANGRUM
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 1:1100 NW 9TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-6061
Mailing Address - Country:US
Mailing Address - Phone:239-245-4033
Mailing Address - Fax:
Practice Address - Street 1:1100 NW 9TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-6061
Practice Address - Country:US
Practice Address - Phone:123-924-5403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105007600Medicaid