Provider Demographics
NPI:1477296572
Name:KANNAN, MANASAA VIJAY
Entity Type:Individual
Prefix:
First Name:MANASAA
Middle Name:VIJAY
Last Name:KANNAN
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 1:5216 WOLFPEN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9198
Mailing Address - Country:US
Mailing Address - Phone:502-544-0102
Mailing Address - Fax:
Practice Address - Street 1:500 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1702
Practice Address - Country:US
Practice Address - Phone:502-852-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program