Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 307828 | NY |
NPI | 1013461276 |
---|---|
Provider Name | Blayne Manning |
First Address | Great Neck, NY 11021-5503 |
Second Address | Great Neck, NY 11021-5503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2016 |
Last Update Date | 05/08/2016 |