Basic Information
| Provider Information | |||||||||
| NPI: | 1437644770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANZANO | ||||||||
| FirstName: | MARYGRACE | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 844 KEMPSVILLE RD STE 212 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572615977 | ||||||||
| FaxNumber: | 7572759913 | ||||||||
| Practice Location | |||||||||
| Address1: | 844 KEMPSVILLE RD STE 212 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572615977 | ||||||||
| FaxNumber: | 7572759913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2018 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024176270 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 0024176270 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LC0200X | 0024176270 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LA2100X | 0024176270 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.