Healthcare Provider Details

I. General information

NPI: 1649311903
Provider Name (Legal Business Name): KAREN ANN MANFREDONIA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 04/09/2023
Certification Date: 04/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 SHELLEY RENEE LN
CORDOVA TN
38018-4366
US

IV. Provider business mailing address

673 SHELLEY RENEE LN
CORDOVA TN
38018-4366
US

V. Phone/Fax

Practice location:
  • Phone: 310-977-6674
  • Fax:
Mailing address:
  • Phone: 310-977-6674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT24660
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000007151
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: