Provider Demographics
NPI:1407576176
Name:MANKUS, KRISTEN LORRAINE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LORRAINE
Last Name:MANKUS
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 1:186 PLATT LN
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2056
Mailing Address - Country:US
Mailing Address - Phone:203-887-3237
Mailing Address - Fax:
Practice Address - Street 1:2890 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4980
Practice Address - Country:US
Practice Address - Phone:203-375-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner