Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | LZ10405 | LA |
NPI | 1003203282 |
---|---|
Provider Name | Ms. Shannon Wall Mangum |
First Address | New Orleans, LA 70112-2262 |
Second Address | New Orleans, LA 70112-2262 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2015 |
Last Update Date | 24/04/2015 |