Provider Demographics
NPI:1861728883
Name:MANZANO, SHANALEE H (RN)
Entity type:Individual
Prefix:
First Name:SHANALEE
Middle Name:H
Last Name:MANZANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHANALEE
Other - Middle Name:DOREEN HONEY
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-1209
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2135
Practice Address - Street 1:1270 KOTNUM ROAD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-1209
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2135
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5896996-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273855Medicaid
OR273855Medicaid