Provider Demographics
NPI:1982460978
Name:MANGRAM, JZAQUISE (RN)
Entity Type:Individual
Prefix:
First Name:JZAQUISE
Middle Name:
Last Name:MANGRAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 HADDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8422
Mailing Address - Country:US
Mailing Address - Phone:951-334-6190
Mailing Address - Fax:
Practice Address - Street 1:1422 HADDINGTON DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-8422
Practice Address - Country:US
Practice Address - Phone:951-334-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812297163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator