MEDICARE: MRS. KATHLEEN M MANCHESTER NP

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	363LP0200X	Pediatric Nurse Practitioner	230423	MA

General Provider Information

NPI Number	:	1871710707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN M MANCHESTER NP

Provider Business Mailing Address
First Line	:	19 MUZZEY ST
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02421-5256
Country	:	US
Telephone Number	:	781-862-4110
Fax Number	:	781-863-2007

Provider Business Practice Location Address
First Line	:	19 MUZZEY ST
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02421-5256
Country	:	US
Telephone Number	:	781-862-4110
Fax Number	:	781-863-2007

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

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	07/08/2007

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