Provider Demographics
NPI:1104662121
Name:VIFANSI, MANKAA
Entity type:Individual
Prefix:
First Name:MANKAA
Middle Name:
Last Name:VIFANSI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10505 CORPORATE DR STE 105G
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1605
Mailing Address - Country:US
Mailing Address - Phone:224-523-7883
Mailing Address - Fax:
Practice Address - Street 1:3010 GRAND AVE FL 1
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8950
Practice Address - Fax:847-984-5602
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029951363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health