Provider Demographics
NPI:1104534080
Name:MANZANARES, KEIRY GISELLE
Entity type:Individual
Prefix:
First Name:KEIRY
Middle Name:GISELLE
Last Name:MANZANARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 E ROGUES PATH
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2762
Mailing Address - Country:US
Mailing Address - Phone:631-897-4025
Mailing Address - Fax:
Practice Address - Street 1:37 E ROGUES PATH
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2762
Practice Address - Country:US
Practice Address - Phone:631-897-4025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator