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General NPI Number Information
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NPI Number | 1730616319
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Entity Type | Individual
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Provider Name | MARISSA C MANIBOG LPN
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Gender | Female
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Dates
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Enumeration Date | 05/15/2017
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Last Update Date | 05/15/2017
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Provider Practice Location Address
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Address Line | 127 BETH CIR
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City | PLYMOUTH
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State | WI
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Zip | 53073-2649
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Country | US
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Telephone | 920-892-7044
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Fax |
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Provider Business Mailing Address
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Address Line | 603 E PINE ST APT 8
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City | NEW LONDON
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State | WI
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Zip | 54961-1963
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Country | US
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Telephone | 920-475-6804
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 313088-31
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License Number State | WI
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