Provider Demographics
NPI:1033494455
Name:JOSEPH, MANEESHA T (FNP)
Entity Type:Individual
Prefix:MS
First Name:MANEESHA
Middle Name:T
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MANEESHA
Other - Middle Name:T
Other - Last Name:POULOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-556-8300
Mailing Address - Fax:309-556-8295
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 3400
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-556-8300
Practice Address - Fax:309-556-8295
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.394485163WM0705X
NY582593-1163WM0705X
FLRN 9300306163WM0705X
NYF336606-1363LF0000X
IL209.008939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical