Provider Demographics
NPI:1407424443
Name:FANE, MAMAN ASSIATA (RN)
Entity Type:Individual
Prefix:
First Name:MAMAN
Middle Name:ASSIATA
Last Name:FANE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 148TH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-3132
Mailing Address - Country:US
Mailing Address - Phone:917-500-7687
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY738564163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse