Provider Demographics
NPI:1548779457
Name:MANN, JOHN NICHOLAS (NP-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NICHOLAS
Last Name:MANN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:228 RACHEL EVANS DR
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-8395
Mailing Address - Country:US
Mailing Address - Phone:864-612-1042
Mailing Address - Fax:
Practice Address - Street 1:1700 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1041
Practice Address - Country:US
Practice Address - Phone:864-573-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21333363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCB9307628OtherSCB9307628