Provider Demographics
NPI:1033647706
Name:MANU, MARY P
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:MANU
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 1:6017 TRAVO WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-2800
Mailing Address - Country:US
Mailing Address - Phone:916-479-9007
Mailing Address - Fax:
Practice Address - Street 1:6017 TRAVO WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-2800
Practice Address - Country:US
Practice Address - Phone:916-479-9007
Practice Address - Fax:916-479-9007
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006426363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
F03170586OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS
CA95006426OtherCALIFORNIA BOARD OF REGISTERED NURSING