Healthcare Provider Details

I. General information

NPI: 1750597886
Provider Name (Legal Business Name): MANELLEMA NANDIMITRA FERNANDO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W MILWAUKEE ST SUITE 206
JANESVILLE WI
53548-2998
US

IV. Provider business mailing address

15 W MILWAUKEE ST SUITE 206
JANESVILLE WI
53548-2998
US

V. Phone/Fax

Practice location:
  • Phone: 608-756-0791
  • Fax:
Mailing address:
  • Phone: 608-756-0791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number35983-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: