Provider Demographics
NPI:1285386870
Name:MANGHAM, LAURIE ELLEN (RN)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELLEN
Last Name:MANGHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 NW 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2800
Mailing Address - Country:US
Mailing Address - Phone:470-686-9396
Mailing Address - Fax:
Practice Address - Street 1:3 REESE ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2613
Practice Address - Country:US
Practice Address - Phone:770-714-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162180163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management