Provider Demographics
NPI:1649934423
Name:MANGAN, ROBIN JUDITH (LPN)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:JUDITH
Last Name:MANGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:JUDITH
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-0145
Mailing Address - Country:US
Mailing Address - Phone:208-252-7655
Mailing Address - Fax:208-527-3430
Practice Address - Street 1:551 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213-5003
Practice Address - Country:US
Practice Address - Phone:208-252-7655
Practice Address - Fax:208-527-3430
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13232164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13232OtherIDAHO STATE BOARD OF NURSING