Healthcare Provider Details

I. General information

NPI: 1679824924
Provider Name (Legal Business Name): MANISHA GONSALVES DURKEE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANISHA GONSALVES CRNP

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 SURRATTS RD SUITE 208
CLINTON MD
20735-3362
US

IV. Provider business mailing address

7501 SURRATTS RD SUITE 208
CLINTON MD
20735-3362
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-7353
  • Fax: 301-877-5637
Mailing address:
  • Phone: 301-877-7353
  • Fax: 301-877-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17027
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1038868
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC001603
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: