Provider Demographics
NPI:1952593782
Name:MANISCALCO, MARTHA SHAMY (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SHAMY
Last Name:MANISCALCO
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:MARIA
Other - Last Name:SHAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP, APRN
Mailing Address - Street 1:300 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3100
Mailing Address - Country:US
Mailing Address - Phone:860-297-2018
Mailing Address - Fax:860-297-2020
Practice Address - Street 1:300 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3100
Practice Address - Country:US
Practice Address - Phone:860-297-2018
Practice Address - Fax:860-297-2020
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003623163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008023694Medicaid
CTC00394Medicare PIN