Provider Demographics
NPI:1154540243
Name:MAMMEN, JENNIFER R (NP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:R
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:2444 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-4025
Practice Address - Country:US
Practice Address - Phone:401-683-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335104363L00000X
RIAPRN01824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02892840Medicaid
NY02892840Medicaid
NYRB4224Medicare PIN