1528739398 NPI number — MS. ELIZABETH GAY MANLEY NURSE PRACTITIONER

Table of content: MS. ELIZABETH GAY MANLEY NURSE PRACTITIONER (NPI 1528739398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528739398 NPI number — MS. ELIZABETH GAY MANLEY NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANLEY
Provider First Name:
ELIZABETH
Provider Middle Name:
GAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1528739398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
58383 29 PALMS HWY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUCCA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92284-5891
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-228-5864
Provider Business Mailing Address Fax Number:
760-365-9184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58383 29 PALMS HWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-228-5864
Provider Business Practice Location Address Fax Number:
760-365-9184
Provider Enumeration Date:
09/22/2021

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: 363LG0600X , with the licence number:  95018260 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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