Provider Demographics
NPI:1760135867
Name:MANEJA, LISHEN ANGELIE
Entity Type:Individual
Prefix:
First Name:LISHEN
Middle Name:ANGELIE
Last Name:MANEJA
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 1:2942 BILOXI TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4240
Mailing Address - Country:US
Mailing Address - Phone:347-209-7571
Mailing Address - Fax:
Practice Address - Street 1:8700 A C SKINNER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0836
Practice Address - Country:US
Practice Address - Phone:904-642-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18737224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant