Provider Demographics
NPI:1992467955
Name:BOEHNERT, MANDY MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:BOEHNERT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SEABURY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-5618
Mailing Address - Country:US
Mailing Address - Phone:860-243-4022
Mailing Address - Fax:
Practice Address - Street 1:200 SEABURY DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-5618
Practice Address - Country:US
Practice Address - Phone:860-243-4022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035656164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075383OtherCCN