Provider Demographics
NPI:1861447930
Name:KINGMAN, ANN M (NP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:KINGMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 WASHINGTON ST
Mailing Address - Street 2:# 1
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1177
Mailing Address - Country:US
Mailing Address - Phone:508-238-8646
Mailing Address - Fax:508-230-9772
Practice Address - Street 1:235 NORTH PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-427-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172615363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0369161Medicaid
P30103Medicare UPIN
MANP3209Medicare ID - Type Unspecified