=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164672564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE MANIS R.N., GNP, PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2008
-----------------------------------------------------
Last Update Date | 10/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2780 MIDDLE COUNTRY RD SUITE 306
-----------------------------------------------------
City | LAKE GROVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11755-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-981-8300
-----------------------------------------------------
Fax | 631-981-8400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2539 PHILLIP CT
-----------------------------------------------------
City | BELLMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11710-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-826-1654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 340114
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | F401230
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------