Provider Demographics
NPI:1467140996
Name:MANIFOLD, JONNETTE ANN
Entity Type:Individual
Prefix:
First Name:JONNETTE
Middle Name:ANN
Last Name:MANIFOLD
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 1:11545 140TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11436-1018
Mailing Address - Country:US
Mailing Address - Phone:347-285-9302
Mailing Address - Fax:
Practice Address - Street 1:772 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-3172
Practice Address - Country:US
Practice Address - Phone:347-843-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331026-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse