Provider Demographics
NPI:1366176398
Name:NIDAMARTHY, MANISHA
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:NIDAMARTHY
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-246-3542
Mailing Address - Fax:856-246-3528
Practice Address - Street 1:1000 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-1132
Practice Address - Country:US
Practice Address - Phone:856-246-3542
Practice Address - Fax:856-246-3528
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1366176398363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner