=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962661694
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDITH MANKIEWICZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2008
-----------------------------------------------------
Last Update Date | 06/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6488 CITORI DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89436-7393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-586-1859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2293
-----------------------------------------------------
City | STATELINE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89449-2293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-586-1859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A0205
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------