Provider Demographics
NPI:1851388599
Name:MANUEL, MARY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MANUEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29811 CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91384-4540
Mailing Address - Country:US
Mailing Address - Phone:661-618-5518
Mailing Address - Fax:
Practice Address - Street 1:11211 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1115
Practice Address - Country:US
Practice Address - Phone:818-837-5770
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN396105363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS70556Medicare UPIN