Healthcare Provider Details

I. General information

NPI: 1063437754
Provider Name (Legal Business Name): SUSAN T. MANABO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26455 MARSALA WAY
MISSION VIEJO CA
92692-3264
US

IV. Provider business mailing address

1800 WILSHIRE BLVD
LOS ANGELES CA
90057-3602
US

V. Phone/Fax

Practice location:
  • Phone: 949-348-0476
  • Fax: 213-484-9939
Mailing address:
  • Phone: 949-348-0476
  • Fax: 213-484-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number285624-11204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: