Basic Information
| Provider Information | |||||||||
| NPI: | 1457327272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGUN | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARNEY | ||||||||
| OtherFirstName: | JENNIE | ||||||||
| OtherMiddleName: | CRAIG | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 896206 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526361919 | ||||||||
| FaxNumber: | 2526362656 | ||||||||
| Practice Location | |||||||||
| Address1: | 2636 DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285624238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526361919 | ||||||||
| FaxNumber: | 2526362656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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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 | 208000000X | 009000700 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 141Y6 | 01 | NC | BCBSNC | OTHER | 5903648 | 05 | NC | MEDICAID |