Form 3 State Licensure

the

DataBank

DCN: 5950000090960809
Process Date: 12/11/2014
Page: 1
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

MANN, ANITTA
LICENSING BOARD
STATE LICENSURE ACTION

Date of Action: 11/11/2014

Initial Action

Basis for Initial Action

- REVOCATION OF LICENSE
- PRESCRIPTIVE AUTHORITY ACTION, SEE SECTION C.
OF THE REPORT FOR DETAILS
- PUBLICLY AVAILABLE NEGATIVE ACTION OR FINDING,
SEE SECTION C. OF THE REPORT FOR DETAILS
- OTHER LICENSURE ACTION, SEE SECTION C. OF THE
REPORT FOR DETAILS
A. REPORTING
ENTITY

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Subject Name:
Other Name(s) Used:
Gender:
Date of Birth:
Organization Name:
Work Address:
City, State, ZIP:
Organization Type:
Home Address:
City, State, ZIP:
Deceased:
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
National Provider Identifiers (NPI):
Professional School(s) & Year(s) of Graduation:

B. SUBJECT
IDENTIFICATION
INFORMATION
(INDIVIDUAL)

- DEFAULT ON HEALTH EDUCATION LOAN OR
SCHOLARSHIP OBLIGATIONS

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
GENERAL HOSPITAL
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
GENERAL/ACUTE CARE HOSPITAL (301)
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111

KENT STATE UNIVERSITY COLLEGE OF PODIATRIC MEDICINE
(2000)
Occupation/Field of Licensure (Code): PODIATRIST
State License Number, State of Licensure: SL56, MD
Drug Enforcement Administration (DEA) Numbers: AM111111111
Unique Physician Identification Numbers (UPIN):
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.): TEST
Business Address of Affiliate: 4350 FAIR LAKES CT STE 100
City, State, ZIP: FAIRFAX, VA 22033-4233

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960809
Process Date: 12/11/2014
Page: 2
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Nature of Relationship(s): SUBJECT IS EMPLOYEE OF AFFILIATE OR ASSOCIATE (200)
Type of Adverse Action: STATE LICENSURE
Basis for Action: DEFAULT ON HEALTH EDUCATION LOAN OR SCHOLARSHIP
OBLIGATIONS (44)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: INTEGRITY PROGRAM
Adverse Action
Classification Code(s): REVOCATION OF LICENSE (1110)
PRESCRIPTIVE AUTHORITY ACTION, SPECIFY (1179)
Other, as Specified: TEST
PUBLICLY AVAILABLE NEGATIVE ACTION OR FINDING, SPECIFY
(1189)
Other, as Specified: TEST
OTHER LICENSURE ACTION - NOT CLASSIFIED, SPECIFY (1199)
Other, as Specified: TEST
Date Action Was Taken: 11/11/2014
Date Action Became Effective: 11/11/2014
Length of Action: SPECIFIC PERIOD
Years: 2
Months: 6
Days:
Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 2,000.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES, WITH CONDITIONS (REQUIRES A REVISION TO ACTION
REPORT WHEN STATUS CHANGES)
Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: TEST

C. INFORMATION
REPORTED

X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 02/12/2015

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960809
Process Date: 12/11/2014
Page: 3
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov
Date of Original Submission:

12/11/2014

Date of Most Recent Change:

12/11/2014

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only for
the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal law.
For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960810
Process Date: 12/11/2014
Page: 1
of
3
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

FOOTCAREINC.
LICENSING BOARD
STATE LICENSURE ACTION

Date of Action: 11/26/2014

Initial Action

Basis for Initial Action

- REVOCATION OF LICENSE OR CERTIFICATE
- SUSPENSION OF LICENSE OR CERTIFICATE
- REPRIMAND OR CENSURE
- OTHER LICENSURE ACTION, SEE SECTION C. OF THE
REPORT FOR DETAILS
A. REPORTING
ENTITY

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Organization Name:
Other Organization Name(s) Used:
Business Address:
City, State, ZIP:
Organization Type:
Names and Titles of Principal Officers and Owners (POO):
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
State License Number, State of Licensure:
Is the Subject a health care entity that provides health care
services and engages in a formal peer review process for the
purpose of furthering quality health care?:
Drug Enforcement Administration (DEA) Numbers:
Clinical Laboratory Act (CLIA) Numbers:
Food and Drug Administration (FDA) Numbers:
National Provider Identifiers (NPI):
Medicare Provider/Supplier Numbers:
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.):
Business Address of Affiliate:
City, State, ZIP:
Nature of Relationship(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(ORGANIZATION)

- EXCLUSION OR SUSPENSION FROM A FEDERAL OR
STATE HEALTH CARE PROGRAM

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
FOOTCAREINC.
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
CHIROPRACTIC GROUP/PRACTICE (361)
MANN, ANITTA
111111111

SL89, MD

YES

FOOTCAREINC2

SUBJECT IS SUBSIDIARY OF AFFILIATE OR ASSOCIATE (600)

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960810
Process Date: 12/11/2014
Page: 2
of
3
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Type of Adverse Action: STATE LICENSURE
Basis for Action: EXCLUSION OR SUSPENSION FROM A FEDERAL OR STATE HEALTH
CARE PROGRAM (40)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: INTEGRITY PROGRAM
Adverse Action
Classification Code(s): REVOCATION OF LICENSE OR CERTIFICATE (3111)
SUSPENSION OF LICENSE OR CERTIFICATE (3136)
REPRIMAND OR CENSURE (3138)
OTHER LICENSURE ACTION - NOT CLASSIFIED, SPECIFY (3239)
Other, as Specified: TEST
Date Action Was Taken: 11/26/2014
Date Action Became Effective: 11/26/2014
Length of Action: SPECIFIC PERIOD
Years: 1
Months: 6
Days:
Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 2,000.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: NO
Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: PRACTITIONER INJURED THREE PATIENTS, SO LICENSE HAS BEEN
REVOKED. HE WILL BE EXCLUDED FROM PARTICIPATING IN
FEDERAL HEALTH CARE PROGRAMS.

C. INFORMATION
REPORTED

X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 01/30/2015

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960810
Process Date: 12/11/2014
Page: 3
of
3
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov
Date of Original Submission:

12/11/2014

Date of Most Recent Change:

12/11/2014

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only for
the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal law.
For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

Non-visible Questions
Label

Why does the subject not
have a license?

The action(s) reported
relate primarily to this
occupation/license

State Changes
Label
Occupation/Field of
Licensure Modal
Basis for Action Modal

PDF Name
Location
(page/section
header)
SL New
Below “Unlicensed/No
(1/Occupation and license number for this
State Licensure
occupation”
Information)
SL New
Below each “State”
(1/Occupation and
State Licensure
Information)

PDF Name
SL SubjectInfo
Occupation

Item Type
Modal

SL ActionInfo
Basis

Modal

Response
Input Item

Visibility Trigger

Radio buttons

If user checks "Unlicensed/No
license number for this
occupation

Radio button

If user enters more than one
License/Profession

Visibility Trigger
When the “Occupation/Field of Licensure” text box is selected the
Occupation or Field of Licensure modal shown in the SL
SubjectInfo Occupation PDF appears.
When the “Basis for Action” text box is selected the Basis for
Action modal shown in the SL ActionInfo Basis PDF appears.

Other

Possible answers:
State license expired
Never had a valid state license
Licensed in another state
Don’t know