Basic Information
| Provider Information | |||||||||
| NPI: | 1366795908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGUM | ||||||||
| FirstName: | TERRA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MN, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | #207 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703554 | ||||||||
| Practice Location | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | #207 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2012 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60314389 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.