Provider Demographics
NPI:1720214794
Name:BAGWELL, MANDIE E (APN)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:E
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1980
Mailing Address - Country:US
Mailing Address - Phone:618-985-4344
Mailing Address - Fax:618-985-6469
Practice Address - Street 1:310 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1980
Practice Address - Country:US
Practice Address - Phone:618-985-4344
Practice Address - Fax:618-985-6469
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007566363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily