Basic Information
| Provider Information | |||||||||
| NPI: | 1538429865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR MANGES | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAIR | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 PLEASANT ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415743 | ||||||||
| FaxNumber: | 5152416474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 00 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SX0200X | A107192 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology | 363L00000X | A107192 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.