Healthcare Provider Details

I. General information

NPI: 1538871496
Provider Name (Legal Business Name): JOHN L MANDEVILLE FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 STATE ROUTE 101 UNIT 2
AMHERST NH
03031-1706
US

IV. Provider business mailing address

282 STATE ROUTE 101 UNIT 2
AMHERST NH
03031-1706
US

V. Phone/Fax

Practice location:
  • Phone: 603-693-2100
  • Fax: 603-679-1046
Mailing address:
  • Phone: 603-693-2100
  • Fax: 603-679-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number079027-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: