=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033367842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN WANGECI MANYARA RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2008
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 NORTH GREENE STREET BALTIMOR VA MEDICAL CENTER
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-605-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2816 KINGS GIFT DR
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21042-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-531-8490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | R107884
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------