Provider Demographics
NPI:1043095250
Name:MANZANILLO, ELISE (NP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:MANZANILLO
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 1:100 HAVEN AVE APT 4F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2622
Mailing Address - Country:US
Mailing Address - Phone:925-305-5915
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352061363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily