Provider Demographics
NPI:1336730571
Name:MANALO, MARY CAROLINE E. MACAM (NP)
Entity Type:Individual
Prefix:
First Name:MARY CAROLINE E.
Middle Name:MACAM
Last Name:MANALO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6511 NEBULA CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677
Mailing Address - Country:US
Mailing Address - Phone:951-756-3618
Mailing Address - Fax:
Practice Address - Street 1:701 PLEASANT GROVE BLVD #125
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678
Practice Address - Country:US
Practice Address - Phone:916-784-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95016452363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care