Healthcare Provider Details

I. General information

NPI: 1811548019
Provider Name (Legal Business Name): MANUEL CIFUENTES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2019
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 WILLOWBROOK RD
STATEN ISLAND NY
10314-6826
US

IV. Provider business mailing address

646 WILLOWBROOK RD
STATEN ISLAND NY
10314-6826
US

V. Phone/Fax

Practice location:
  • Phone: 786-608-3233
  • Fax:
Mailing address:
  • Phone: 786-608-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349509
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number742550-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: