Provider Demographics
NPI:1245270461
Name:MANLEY, GWEN A (FNP)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:A
Last Name:MANLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-1214
Mailing Address - Country:US
Mailing Address - Phone:607-865-5800
Mailing Address - Fax:607-510-4253
Practice Address - Street 1:157 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1521
Practice Address - Country:US
Practice Address - Phone:607-336-2400
Practice Address - Fax:607-334-5618
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332297363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02282108Medicaid
NY02282108Medicaid
NYBB2111Medicare PIN