Provider Demographics
NPI:1689197956
Name:MANISCALCO, LYLLETTE
Entity Type:Individual
Prefix:
First Name:LYLLETTE
Middle Name:
Last Name:MANISCALCO
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 1:1411 72ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-1711
Mailing Address - Country:US
Mailing Address - Phone:212-444-2386
Mailing Address - Fax:
Practice Address - Street 1:1411 72ND ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1711
Practice Address - Country:US
Practice Address - Phone:212-444-2386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12170461744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study