1649934423 NPI number — ROBIN JUDITH MANGAN LPN

Table of content: ROBIN JUDITH MANGAN LPN (NPI 1649934423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649934423 NPI number — ROBIN JUDITH MANGAN LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGAN
Provider First Name:
ROBIN
Provider Middle Name:
JUDITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROSS
Provider Other First Name:
ROBIN
Provider Other Middle Name:
JUDITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649934423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83213-0145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-252-7655
Provider Business Mailing Address Fax Number:
208-527-3430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 HIGHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83213-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-252-7655
Provider Business Practice Location Address Fax Number:
208-527-3430
Provider Enumeration Date:
10/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  13232 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13232 . This is a "IDAHO STATE BOARD OF NURSING" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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