Provider Demographics
NPI:1093429847
Name:MANDIA, KRISTEN NICOLE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:MANDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 PRESTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3906
Practice Address - Country:US
Practice Address - Phone:732-744-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04291000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist