Healthcare Provider Details

I. General information

NPI: 1720583388
Provider Name (Legal Business Name): NITYA MANNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 W OUTER DR
DETROIT MI
48235
US

IV. Provider business mailing address

899 LONE PINE RD
BLOOMFIELD HILLS MI
48302-2430
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-3250
  • Fax: 313-966-1738
Mailing address:
  • Phone: 248-986-7948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301503996
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: