Provider Demographics
NPI:1427483817
Name:MANGULABNAN, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MANGULABNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 654
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-0654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 PORT NEAL RD
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-8098
Practice Address - Country:US
Practice Address - Phone:712-943-3837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000936224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant