Provider Demographics
NPI:1396974820
Name:CARLSON, MANDY RENAE (RN, FNP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:RENAE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:RENAE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:102 W GRUENTHER RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-4828
Mailing Address - Country:US
Mailing Address - Phone:402-332-2772
Mailing Address - Fax:402-332-5446
Practice Address - Street 1:102 W GRUENTHER RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-4828
Practice Address - Country:US
Practice Address - Phone:402-332-2772
Practice Address - Fax:402-332-5446
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111224363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098684137Medicare PIN
NE099928037Medicare PIN