Provider Demographics
NPI:1770842494
Name:MANGUM, LAUREN COLBY (PHD, LAT, ATC)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:COLBY
Last Name:MANGUM
Suffix:
Gender:F
Credentials:PHD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 SCORPIUS STREET HS2 ROOM 235
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32816-0001
Mailing Address - Country:US
Mailing Address - Phone:407-823-2795
Mailing Address - Fax:
Practice Address - Street 1:4364 SCORPIUS STREET HS2 ROOM 235
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-2455
Practice Address - Country:US
Practice Address - Phone:407-823-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11682255A2300X
FLAL54472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer