Provider Demographics
NPI:1770896953
Name:MANGON, TANISHA (MSN, APRN, NP-C)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:MANGON
Suffix:
Gender:
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12202 QUIET MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:MEADOWS PLACE
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2258
Mailing Address - Country:US
Mailing Address - Phone:832-334-8427
Mailing Address - Fax:
Practice Address - Street 1:14090 SOUTHWEST FWY STE 300
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3679
Practice Address - Country:US
Practice Address - Phone:281-524-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709892363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215538407Medicaid
TXTXB154124Medicare PIN