Provider Demographics
NPI:1992677397
Name:MANTIKAS, LAUREN B
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:B
Last Name:MANTIKAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 NEWGATE DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3961
Mailing Address - Country:US
Mailing Address - Phone:860-338-0354
Mailing Address - Fax:
Practice Address - Street 1:26 NEWGATE DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-3961
Practice Address - Country:US
Practice Address - Phone:860-338-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2351883363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care