1518118611 NPI number — STEPHANIE MICHELE MANNIKKO DPT, MCMT

Table of content: STEPHANIE MICHELE MANNIKKO DPT, MCMT (NPI 1518118611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518118611 NPI number — STEPHANIE MICHELE MANNIKKO DPT, MCMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANNIKKO
Provider First Name:
STEPHANIE
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT, MCMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518118611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 SE 4TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33060-8013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-406-0312
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3325 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-6999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-986-2299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 25244 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP2384 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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