Healthcare Provider Details

I. General information

NPI: 1851150833
Provider Name (Legal Business Name): MANIFEST WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 EASTERN BLVD STE A
MIDDLE RIVER MD
21220-4296
US

IV. Provider business mailing address

2201 EASTERN AVE APT A
BALTIMORE MD
21231-3734
US

V. Phone/Fax

Practice location:
  • Phone: 410-774-6769
  • Fax: 443-596-0057
Mailing address:
  • Phone: 410-774-6769
  • Fax: 443-596-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GENEVIEVE IFEANYICHUKWU
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 443-531-4264