Healthcare Provider Details

I. General information

NPI: 1043153042
Provider Name (Legal Business Name): MANVI PUNUKOLLU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 ROZZELLES FERRY RD
CHARLOTTE NC
28208-4228
US

IV. Provider business mailing address

4723 VILLAGE DR
FAIRFAX VA
22030-5721
US

V. Phone/Fax

Practice location:
  • Phone: 704-446-9987
  • Fax:
Mailing address:
  • Phone: 703-223-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: