Basic Information
| Provider Information | |||||||||
| NPI: | 1760421093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANNS | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 SHERMAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST. JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05819 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 97 SHERMAN DR | ||||||||
| Address2: | ST. JOHNSBURY PEDIATRICS | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027485131 | ||||||||
| FaxNumber: | 8027484237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1010010350 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1005218 | 05 | VT | MEDICAID | 30008265 | 05 | NH | MEDICAID |