Provider Demographics
NPI:1992224588
Name:VANG, MANIVAN THOR (RN)
Entity Type:Individual
Prefix:
First Name:MANIVAN
Middle Name:THOR
Last Name:VANG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3933
Mailing Address - Country:US
Mailing Address - Phone:608-217-3642
Mailing Address - Fax:608-856-0440
Practice Address - Street 1:2110 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3933
Practice Address - Country:US
Practice Address - Phone:608-217-3642
Practice Address - Fax:608-856-0440
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI116073-30163WH0200X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health