Provider Demographics
NPI:1760229439
Name:VADALI, MANISHA (STUDENT)
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:VADALI
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 NW GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 NW GOODMAN ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-8502
Practice Address - Country:US
Practice Address - Phone:240-646-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program