Provider Demographics
NPI:1437694023
Name:KERNIZAN, MANOUSHKA FABIENNE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MANOUSHKA
Middle Name:FABIENNE
Last Name:KERNIZAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PORTER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2830
Mailing Address - Country:US
Mailing Address - Phone:617-669-6870
Mailing Address - Fax:
Practice Address - Street 1:75 PORTER ST APT 1
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2830
Practice Address - Country:US
Practice Address - Phone:617-669-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA94714164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse