Healthcare Provider Details

I. General information

NPI: 1033367842
Provider Name (Legal Business Name): SUSAN WANGECI MANYARA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NORTH GREENE STREET BALTIMOR VA MEDICAL CENTER
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

2816 KINGS GIFT DR
ELLICOTT CITY MD
21042-2032
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7000
  • Fax:
Mailing address:
  • Phone: 410-531-8490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR107884
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: