Basic Information
| Provider Information | |||||||||
| NPI: | 1033367842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANYARA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | WANGECI | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2816 KINGS GIFT DR | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210422032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105318490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 NORTH GREENE STREET | ||||||||
| Address2: | BALTIMOR VA MEDICAL CENTER | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | R107884 | MD | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.