Provider Demographics
NPI:1295394526
Name:MCMANAMAN, ELISE (NP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:MCMANAMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:M
Other - Last Name:MAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8081 INNOVATION PARK DR STE 775
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4867
Mailing Address - Country:US
Mailing Address - Phone:571-308-1830
Mailing Address - Fax:571-308-1843
Practice Address - Street 1:8081 INNOVATION PARK DR STE 775
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-308-1830
Practice Address - Fax:571-308-1843
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR232320363LW0102X
VA0024177602363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2014107550Medicaid