Healthcare Provider Details

I. General information

NPI: 1619396470
Provider Name (Legal Business Name): NITISH JASMINE MANNING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 CARATOKE HWY
MOYOCK NC
27958
US

IV. Provider business mailing address

PO BOX 11314
BELFAST ME
04915-4004
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6621
  • Fax: 235-435-2685
Mailing address:
  • Phone: 757-842-4481
  • Fax: 757-312-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116026979
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2017-01598
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: