Provider Demographics
NPI:1144999434
Name:MANNINO, KATIE LYNN (PA)
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:LYNN
Last Name:MANNINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 8TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4163
Mailing Address - Country:US
Mailing Address - Phone:732-546-7122
Mailing Address - Fax:
Practice Address - Street 1:440 CURRY AVE STE A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1794
Practice Address - Country:US
Practice Address - Phone:201-227-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00638700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant