Provider Demographics
NPI:1669917654
Name:MANGRUM, DEBRA D (NP)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:D
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3800 W 203RD ST STE 204
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1185
Practice Address - Country:US
Practice Address - Phone:708-852-2641
Practice Address - Fax:708-503-3260
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71007051A363LA2200X
IL209015375363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300024535Medicaid