Provider Demographics
NPI:1891063822
Name:MANCHO, PRUDENCE ASHIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:ASHIE
Last Name:MANCHO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 ENGLISH TURN DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7341
Mailing Address - Country:US
Mailing Address - Phone:301-807-6957
Mailing Address - Fax:
Practice Address - Street 1:14221 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-2225
Practice Address - Country:US
Practice Address - Phone:301-807-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR-149483363L00000X
MD2011002215363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR-149483OtherADVANCE PRACTICE REGISTER NURSE