Healthcare Provider Details

I. General information

NPI: 1851357966
Provider Name (Legal Business Name): TRINI LARS JEANICE II NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MANNHEIM HEALTH CLINIC BENJAMIN FRANKLIN VILLAGE UNIT 29920
APO AE
09267
DE

IV. Provider business mailing address

ATTN: CREDENTIALS OFFICE CMR 442
APO AE
A09042
DE

V. Phone/Fax

Practice location:
  • Phone: 496217301750
  • Fax: 496217304665
Mailing address:
  • Phone: 4906221172274
  • Fax: 4906221172941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR116826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: