Provider Demographics
NPI:1376971838
Name:MANNKE, KRISTIN L
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:MANNKE
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 1:526 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3301
Mailing Address - Country:US
Mailing Address - Phone:978-371-7010
Mailing Address - Fax:978-371-0522
Practice Address - Street 1:92 MONTVALE AVE STE 3000
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3658
Practice Address - Country:US
Practice Address - Phone:781-438-6350
Practice Address - Fax:781-279-0430
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201393178NP-PP363LF0000X
MARN262875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily