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General NPI Number Information
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NPI Number | 1760121008
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Entity Type | Individual
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Provider Name | KARLIE ANN MANDZIARA
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Gender | Female
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Dates
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Enumeration Date | 06/03/2022
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 1140 E MICHIGAN AVE STE 400
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City | LANSING
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State | MI
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Zip | 48912-1806
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Country | US
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Telephone | 517-285-2764
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Fax |
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Provider Business Mailing Address
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Address Line | 8790 FLAT CREEK DR UNIT D
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City | ROCKFORD
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State | MI
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Zip | 49341-8948
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Country | US
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Telephone | 517-285-2764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601011186
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License Number State | MI
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