Provider Demographics
NPI:1548862386
Name:MANGUM, NICOLE D
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:MANGUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29680 HIGHWAY 50 E
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-5589
Mailing Address - Country:US
Mailing Address - Phone:662-605-0382
Mailing Address - Fax:
Practice Address - Street 1:29680 HIGHWAY 50 E
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-5589
Practice Address - Country:US
Practice Address - Phone:662-605-0382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)