Provider Demographics
NPI:1124798400
Name:MANNESS, DARA
Entity type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:MANNESS
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 1:2 OLD FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WEST SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06093-2829
Mailing Address - Country:US
Mailing Address - Phone:860-670-7067
Mailing Address - Fax:
Practice Address - Street 1:275 STEELE RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2716
Practice Address - Country:US
Practice Address - Phone:860-570-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT143291163W00000X
390200000X
CT12198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program