Provider Demographics
NPI:1871634188
Name:MANNINO, KAREN A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:A
Last Name:MANNINO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10607 RANDOLPH ST
Mailing Address - Street 2:STE C
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7505
Mailing Address - Country:US
Mailing Address - Phone:219-663-1841
Mailing Address - Fax:219-663-1846
Practice Address - Street 1:10607 RANDOLPH ST
Practice Address - Street 2:STE C
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7505
Practice Address - Country:US
Practice Address - Phone:219-663-1841
Practice Address - Fax:219-663-1846
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001692A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201001970Medicaid
INM400036301Medicare PIN