Provider Demographics
NPI:1902912256
Name:MANGAN, JULIA B (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:B
Last Name:MANGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2474
Mailing Address - Country:US
Mailing Address - Phone:208-664-8818
Mailing Address - Fax:208-664-4427
Practice Address - Street 1:1112 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2474
Practice Address - Country:US
Practice Address - Phone:208-664-8818
Practice Address - Fax:208-664-4427
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP334A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805117600Medicaid
IDS44842Medicare UPIN
ID805117600Medicaid