MEDICARE: NIKKI J MANN GNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	28157094A	IN

General Provider Information

NPI Number	:	1336278753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKKI J MANN GNP-C

Provider Business Mailing Address
First Line	:	3010 INDEPENDENCE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-1328
Country	:	US
Telephone Number	:	260-478-6240
Fax Number	:	260-527-4802

Provider Business Practice Location Address
First Line	:	3010 INDEPENDENCE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-1328
Country	:	US
Telephone Number	:	260-739-5821
Fax Number	:	260-527-4802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	02/02/2018

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