Provider Demographics
NPI:1083811376
Name:MANCE, MARTHA J (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:MANCE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1078
Mailing Address - Country:US
Mailing Address - Phone:508-230-7288
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND AVE STE 302
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2753
Practice Address - Country:US
Practice Address - Phone:401-633-1100
Practice Address - Fax:401-633-0047
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00199363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics