MEDICARE: LAUREL PORTERFIELD MANLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1780932558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL PORTERFIELD MANLY

Provider Business Mailing Address
First Line	:	12 FADA LANE
Second Line	:
City	:	WEST SHOKAN
State	:	NY
Zip	:	12494-0122
Country	:	US
Telephone Number	:	845-657-4171
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 FADA LANE
Second Line	:
City	:	WEST SHOKAN
State	:	NY
Zip	:	12494-0122
Country	:	US
Telephone Number	:	845-657-4171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2012
Last Update Date	:	07/21/2022

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