Provider Demographics
NPI:1295142339
Name:MANKUTA, TRACI CONRAD (MAED)
Entity type:Individual
Prefix:PROF
First Name:TRACI
Middle Name:CONRAD
Last Name:MANKUTA
Suffix:
Gender:F
Credentials:MAED
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:GABRIELLE
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 WOODLAKE DR E
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2317
Mailing Address - Country:US
Mailing Address - Phone:516-802-2767
Mailing Address - Fax:516-484-4150
Practice Address - Street 1:30 WOODLAKE DR E
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2317
Practice Address - Country:US
Practice Address - Phone:516-802-2767
Practice Address - Fax:516-484-4150
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY842527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist