Healthcare Provider Details

I. General information

NPI: 1225631435
Provider Name (Legal Business Name): PAULINE N MANCHO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TAYLOR AT MARION ST
COLUMBIA SC
29212
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5010
  • Fax:
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24134
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: