Provider Demographics
NPI:1194061549
Name:MANZELLA, STEPHANIE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:MANZELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 S KIHEI RD STE 120
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-5222
Mailing Address - Country:US
Mailing Address - Phone:808-891-6800
Mailing Address - Fax:
Practice Address - Street 1:1279 S KIHEI RD STE 120
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-5222
Practice Address - Country:US
Practice Address - Phone:808-891-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016309363AM0700X
HIAMD-753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical