Provider Demographics
NPI:1912295619
Name:PANWALA, MANISHA (RD)
Entity type:Individual
Prefix:MS
First Name:MANISHA
Middle Name:
Last Name:PANWALA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ENGLE ST APT 6U
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2826
Mailing Address - Country:US
Mailing Address - Phone:917-415-0504
Mailing Address - Fax:
Practice Address - Street 1:18 ENGLE ST APT 6U
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-2826
Practice Address - Country:US
Practice Address - Phone:917-415-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ933723133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic