Provider Demographics
NPI:1528149804
Name:MANDICHAK, DEANNA (PT)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:MANDICHAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6548 S MCCARRAN BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6150
Mailing Address - Country:US
Mailing Address - Phone:775-788-5599
Mailing Address - Fax:775-788-5598
Practice Address - Street 1:6548 S MCCARRAN BLVD
Practice Address - Street 2:STE A
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6150
Practice Address - Country:US
Practice Address - Phone:775-788-5599
Practice Address - Fax:775-788-5598
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0971174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBU242ZMedicare PIN