Provider Demographics
NPI:1972268647
Name:MANGUM, KEYONDA
Entity type:Individual
Prefix:
First Name:KEYONDA
Middle Name:
Last Name:MANGUM
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 1:4732 SUNSET LAKE RD
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-8784
Mailing Address - Country:US
Mailing Address - Phone:919-337-6151
Mailing Address - Fax:
Practice Address - Street 1:17001 SEARSTONE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8385
Practice Address - Country:US
Practice Address - Phone:919-234-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant