Provider Demographics
NPI:1457397044
Name:MANGUM, CONNIE WEST (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:WEST
Last Name:MANGUM
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 WESTON CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-2560
Mailing Address - Country:US
Mailing Address - Phone:910-426-5361
Mailing Address - Fax:
Practice Address - Street 1:2823 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5403
Practice Address - Country:US
Practice Address - Phone:910-483-4002
Practice Address - Fax:910-483-8462
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC53812OtherBCBS PROVIDER #
NC7412046Medicaid