Provider Demographics
NPI:1124674817
Name:MANNINO, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MANNINO
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 1:3680 DEMOTT AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3524
Mailing Address - Country:US
Mailing Address - Phone:516-849-2718
Mailing Address - Fax:
Practice Address - Street 1:3680 DEMOTT AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3524
Practice Address - Country:US
Practice Address - Phone:516-849-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist