Provider Demographics
NPI:1073520052
Name:MANNINO, LINDA ANN (APRN BC MSN CNP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANN
Last Name:MANNINO
Suffix:
Gender:F
Credentials:APRN BC MSN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25195 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4909
Mailing Address - Country:US
Mailing Address - Phone:586-775-4594
Mailing Address - Fax:586-775-4506
Practice Address - Street 1:25195 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4909
Practice Address - Country:US
Practice Address - Phone:586-775-4594
Practice Address - Fax:586-775-4506
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704148987363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500 866 4760OtherBCBS
MI496016910Medicaid
MIOH-26467022OtherMEDICARE ID
MIS90082Medicare UPIN