Provider Demographics
NPI:1063718518
Name:MANN, CHRISTINA ANNETTE (C,N,M)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ANNETTE
Last Name:MANN
Suffix:
Gender:F
Credentials:C,N,M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3301
Mailing Address - Country:US
Mailing Address - Phone:270-781-3415
Mailing Address - Fax:270-781-2091
Practice Address - Street 1:1805 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3301
Practice Address - Country:US
Practice Address - Phone:270-781-3415
Practice Address - Fax:270-781-2091
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06339367A00000X
LARN103468367A00000X
TNAPN16861367A00000X
KYCNM0287367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK130140OtherMEDICARE PTAN INDIVIDUAL
KYK048220OtherMEDICARE GROUP PTAN