Provider Demographics
NPI:1679018683
Name:MANUS, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:MANUS
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:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1199
Mailing Address - Country:US
Mailing Address - Phone:505-368-5163
Mailing Address - Fax:505-368-5502
Practice Address - Street 1:HWY 64 OLD HIGH SCHOOL ROAD
Practice Address - Street 2:1199
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-1199
Practice Address - Country:US
Practice Address - Phone:505-368-5163
Practice Address - Fax:505-368-5502
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM370295164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicaid