Provider Demographics
NPI:1104349422
Name:MANTIS, JULIE ANN (MS, RN, CNS, BC-ADM,)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:MANTIS
Suffix:
Gender:F
Credentials:MS, RN, CNS, BC-ADM,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2901
Mailing Address - Country:US
Mailing Address - Phone:219-703-1013
Mailing Address - Fax:219-836-7983
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-703-1013
Practice Address - Fax:219-836-7983
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7000113A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty