Provider Demographics
NPI:1467136309
Name:FALLATAH, MANAL ISMAIL (RN, BSN, MSN)
Entity Type:Individual
Prefix:MS
First Name:MANAL
Middle Name:ISMAIL
Last Name:FALLATAH
Suffix:
Gender:F
Credentials:RN, BSN, MSN
Other - Prefix:MS
Other - First Name:MANAL
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, BSN, MSN
Mailing Address - Street 1:531 CHAMPIONSHIP DR
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-8810
Mailing Address - Country:US
Mailing Address - Phone:585-200-0553
Mailing Address - Fax:
Practice Address - Street 1:531 CHAMPIONSHIP DR
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-8810
Practice Address - Country:US
Practice Address - Phone:585-200-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY861133-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse