Provider Demographics
NPI:1538484381
Name:MANCHIO, JUDITH E (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:E
Last Name:MANCHIO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 NE MLK JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1112
Mailing Address - Country:US
Mailing Address - Phone:503-775-4931
Mailing Address - Fax:503-788-7285
Practice Address - Street 1:3727 NE MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1112
Practice Address - Country:US
Practice Address - Phone:503-775-4931
Practice Address - Fax:503-788-7285
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60146972363LF0000X
OR201502583NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1538484381Medicaid
WA1538484381Medicaid
WA1538484381Medicaid