Provider Demographics
NPI:1982046199
Name:MANGRUM, CRISTIE TAMAR
Entity Type:Individual
Prefix:MRS
First Name:CRISTIE
Middle Name:TAMAR
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 1:3139 FAIRVIEW ST APT 202
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-3219
Mailing Address - Country:US
Mailing Address - Phone:757-962-3671
Mailing Address - Fax:
Practice Address - Street 1:3139 FAIRVIEW ST APT 202
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-3219
Practice Address - Country:US
Practice Address - Phone:757-962-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist