Provider Demographics
NPI:1114585478
Name:MANZANO, LESLY
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:MANZANO
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 1:20 MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3326
Mailing Address - Country:US
Mailing Address - Phone:718-753-2055
Mailing Address - Fax:
Practice Address - Street 1:20 MARLBORO RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3326
Practice Address - Country:US
Practice Address - Phone:718-753-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist