Provider Demographics
NPI:1457696015
Name:MANNING, NICOLE KELLEY (NP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:KELLEY
Last Name:MANNING
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 1:6 BRENDAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01519-2000
Mailing Address - Country:US
Mailing Address - Phone:508-887-8780
Mailing Address - Fax:
Practice Address - Street 1:102 SHORE DR
Practice Address - Street 2:SUITE 403
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3154
Practice Address - Country:US
Practice Address - Phone:508-856-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236464363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110096015AMedicaid
MA003437701Medicare PIN