Provider Demographics
NPI:1366733560
Name:KRISHNAMENON, MANJU M (ANP)
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:M
Last Name:KRISHNAMENON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 E SCORPIO PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3995
Mailing Address - Country:US
Mailing Address - Phone:602-466-8281
Mailing Address - Fax:
Practice Address - Street 1:1774 E SCORPIO PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-3995
Practice Address - Country:US
Practice Address - Phone:602-466-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP4027363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ67916040Medicaid
AZ67916040Medicaid
AZ67916040Medicare UPIN
AZ67916040Medicare Oscar/Certification
AZ67916040Medicare PIN