Provider Demographics
NPI:1801157995
Name:MANZOLILLO, KATHLEEN MARY
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:MANZOLILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 LOMBARDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTWATERS
Mailing Address - State:NY
Mailing Address - Zip Code:11718-1008
Mailing Address - Country:US
Mailing Address - Phone:631-431-3629
Mailing Address - Fax:
Practice Address - Street 1:476 LOMBARDY BLVD
Practice Address - Street 2:
Practice Address - City:BRIGHTWATERS
Practice Address - State:NY
Practice Address - Zip Code:11718-1008
Practice Address - Country:US
Practice Address - Phone:631-431-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist