Provider Demographics
NPI:1760018006
Name:MANDICZ, KRISTEN ANN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:MANDICZ
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CANAL WAY
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-1266
Mailing Address - Country:US
Mailing Address - Phone:908-892-1952
Mailing Address - Fax:
Practice Address - Street 1:41 JACKSON VALLEY RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-1037
Practice Address - Country:US
Practice Address - Phone:908-892-1952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer