Provider Demographics
NPI:1417079922
Name:MANNING, THERESA (APRN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MANNING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BEACON ST STE 202
Mailing Address - Street 2:HOUSE CALL PROGRAM
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4398
Mailing Address - Country:US
Mailing Address - Phone:617-868-6323
Mailing Address - Fax:
Practice Address - Street 1:120 BEACON ST STE 202
Practice Address - Street 2:HOUSE CALL PROGRAM
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4398
Practice Address - Country:US
Practice Address - Phone:617-868-6323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA192595363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110074832AMedicaid
MANP1088OtherBCBS MA PROVIDER NUMBER
S55339Medicare UPIN
MANP1088Medicare ID - Type Unspecified