Provider Demographics
NPI:1598258014
Name:ABDALLA, MANNAL J (FNP, RN, CSA)
Entity Type:Individual
Prefix:
First Name:MANNAL
Middle Name:J
Last Name:ABDALLA
Suffix:
Gender:F
Credentials:FNP, RN, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18402 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-1284
Mailing Address - Country:US
Mailing Address - Phone:361-633-9838
Mailing Address - Fax:
Practice Address - Street 1:18402 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-1284
Practice Address - Country:US
Practice Address - Phone:361-633-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN181727208600000X
AZCNP230211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ17-603OtherAMERICAN BOARD OF SURGICAL ASSISTANTS; SURGICAL FIRST ASSIST