Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4585 | MN |
NPI | 1003823600 |
---|---|
Provider Name | Ms. Jennifer Nicole Mangan |
First Address | Burnsville, MN 55337-7733 |
Second Address | Burnsville, MN 55337-7733 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
499T6MA | BCBS PRIVODER NUMBER (01) | MN |
V00678 | (02) | MN |