Provider Demographics
NPI:1265659429
Name:MAHNKEN, BRENDA (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MAHNKEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1823
Mailing Address - Country:US
Mailing Address - Phone:508-854-3300
Mailing Address - Fax:
Practice Address - Street 1:91 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3845
Practice Address - Country:US
Practice Address - Phone:508-854-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233914363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC5754Medicare ID - Type UnspecifiedPROVIDER NUMBER
P32068Medicare UPIN