Provider Demographics
NPI:1134873524
Name:MANGENJE, BRIAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MANGENJE
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17866 PLAYER DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-1762
Mailing Address - Country:US
Mailing Address - Phone:248-413-5013
Mailing Address - Fax:
Practice Address - Street 1:17866 PLAYER DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-1762
Practice Address - Country:US
Practice Address - Phone:248-413-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily