Provider Demographics
NPI:1841487949
Name:MANGRUM, ALLISON (DPT)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10328 S 2260 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4401
Mailing Address - Country:US
Mailing Address - Phone:801-865-5645
Mailing Address - Fax:801-733-4334
Practice Address - Street 1:50 N MEDICAL DR # 1R107
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2619
Practice Address - Fax:801-581-2525
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54864492401172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker