Basic Information
| Provider Information | |||||||||
| NPI: | 1396774121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANIFOLD | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 E 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033720000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 140116 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.