Provider Demographics
NPI:1760421093
Name:MANNS, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MANNS
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 1:97 SHERMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:97 SHERMAN DR
Practice Address - Street 2:ST. JOHNSBURY PEDIATRICS
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9280
Practice Address - Country:US
Practice Address - Phone:802-748-5131
Practice Address - Fax:802-748-4237
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010010350363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005218Medicaid
NH30008265Medicaid
VTS26662Medicare UPIN
NH30008265Medicaid