Provider Demographics
NPI:1427617364
Name:MANZANO, NORMA BAJET (CCFFH)
Entity type:Individual
Prefix:
First Name:NORMA
Middle Name:BAJET
Last Name:MANZANO
Suffix:
Gender:F
Credentials:CCFFH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 MALAMALAMA ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2094
Mailing Address - Country:US
Mailing Address - Phone:808-651-4017
Mailing Address - Fax:808-200-0056
Practice Address - Street 1:404 MALAMALAMA ST
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2094
Practice Address - Country:US
Practice Address - Phone:808-651-4017
Practice Address - Fax:808-200-0056
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-190014251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIGE-212-818-7904-01Medicaid