Provider Demographics
NPI:1063655066
Name:SHRESTHA, MANITA (NP)
Entity Type:Individual
Prefix:
First Name:MANITA
Middle Name:
Last Name:SHRESTHA
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 1:29749 PICANA LN FL 2
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-6652
Mailing Address - Country:US
Mailing Address - Phone:917-538-1546
Mailing Address - Fax:
Practice Address - Street 1:550 BROAD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4537
Practice Address - Country:US
Practice Address - Phone:201-822-1161
Practice Address - Fax:877-485-8918
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00230100363LP0808X
NY305032363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0904341Medicaid