Provider Demographics
NPI:1992428239
Name:MANGO, TIFFANY LAJUNE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LAJUNE
Last Name:MANGO
Suffix:
Gender:
Credentials:FNP-BC
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 1344
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-1344
Mailing Address - Country:US
Mailing Address - Phone:337-397-7219
Mailing Address - Fax:
Practice Address - Street 1:328 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4923
Practice Address - Country:US
Practice Address - Phone:337-909-3042
Practice Address - Fax:337-332-5458
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA227157363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily