Basic Information
| Provider Information | |||||||||
| NPI: | 1710589585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANGETT | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4122 W FARRAND RD | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484208243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107309693 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GENESYS PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106065000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704323666 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.