Provider Demographics
NPI:1588257828
Name:COLEY, MANOUCHKA
Entity type:Individual
Prefix:
First Name:MANOUCHKA
Middle Name:
Last Name:COLEY
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 1:100 DE KRUIF PL APT 32L
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-2450
Mailing Address - Country:US
Mailing Address - Phone:917-972-3496
Mailing Address - Fax:
Practice Address - Street 1:100 DE KRUIF PL APT 32L
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-2450
Practice Address - Country:US
Practice Address - Phone:917-972-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346818363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily