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General NPI Number Information
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NPI Number | 1154095677
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Entity Type | Individual
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Provider Name | VYACHESLAV MAMANOV NP
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Gender | Male
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Dates
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Enumeration Date | 08/07/2021
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Last Update Date | 08/07/2021
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Provider Practice Location Address
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Address Line | 10218 64TH AVE
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City | FOREST HILLS
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State | NY
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Zip | 11375-1548
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Country | US
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Telephone | 646-479-9710
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Fax |
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Provider Business Mailing Address
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Address Line | 10218 64TH AVE
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City | FOREST HILLS
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State | NY
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Zip | 11375-1548
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 310305
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License Number State | NY
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