Provider Demographics
NPI:1811622178
Name:MANCHAK, NICOLE (DNP)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MANCHAK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 E SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5215
Mailing Address - Country:US
Mailing Address - Phone:480-281-7979
Mailing Address - Fax:
Practice Address - Street 1:143 E GERMANN RD # B101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0607
Practice Address - Country:US
Practice Address - Phone:480-304-0249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ278085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily