=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730129065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN G MANELLA DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 03/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N HIATUS RD STE 201
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-381-8989
-----------------------------------------------------
Fax | 954-381-8950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N HIATUS ROAD SUITE 201
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-381-8989
-----------------------------------------------------
Fax | 954-381-8950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS4667
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------