Healthcare Provider Details

I. General information

NPI: 1336278753
Provider Name (Legal Business Name): NIKKI J MANN GNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 INDEPENDENCE DR
FORT WAYNE IN
46808-1328
US

IV. Provider business mailing address

3010 INDEPENDENCE DR
FORT WAYNE IN
46808-1328
US

V. Phone/Fax

Practice location:
  • Phone: 260-739-5821
  • Fax: 260-527-4802
Mailing address:
  • Phone: 260-478-6240
  • Fax: 260-527-4802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28157094A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: