Provider Demographics
NPI:1518196781
Name:MANETTA, BRANDY L (NP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:L
Last Name:MANETTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:L
Other - Last Name:MANETTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BRANDON MANETTA
Mailing Address - Street 1:5410 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3022
Mailing Address - Country:US
Mailing Address - Phone:317-445-8381
Mailing Address - Fax:
Practice Address - Street 1:5410 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3022
Practice Address - Country:US
Practice Address - Phone:317-445-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003031363L00000X
IN28165121A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner