Provider Demographics
NPI:1760052468
Name:MANO, VICKY MYRIANE
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:MYRIANE
Last Name:MANO
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 1:6160 ECKHERT RD APT 701
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2759
Mailing Address - Country:US
Mailing Address - Phone:210-367-5009
Mailing Address - Fax:
Practice Address - Street 1:2833 BABCOCK RD STE 302I
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4896
Practice Address - Country:US
Practice Address - Phone:210-450-9890
Practice Address - Fax:210-450-4985
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1044878363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNAMedicaid