Healthcare Provider Details

I. General information

NPI: 1487610366
Provider Name (Legal Business Name): PATRICIA FANNYA MANCHAK P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 PHILADELPHIA PIKE
CLAYMONT DE
19703-2568
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 302-408-7310
  • Fax: 302-416-4817
Mailing address:
  • Phone: 631-580-5200
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT009427L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0001028
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: