Form 8 Professional Society

the

DataBank

DCN: 5950000090960756
Process Date: 11/25/2014
Page: 1
of
2
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
PROFESSIONAL SOCIETY ACTION

Date of Action: 11/25/2014

Initial Action
- REVOCATION OF PROFESSIONAL SOCIETY
MEMBERSHIP

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:
Home Address:
City, State, ZIP:
Deceased:
Social Security Numbers (SSN):
Professional School(s) & Year(s) of Graduation:
Occupation/Field of Licensure (Code):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) 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
(INDIVIDUAL)

Basis for Initial Action
- CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR
REVOKED BY ANOTHER HOSPITAL OR HEALTH CARE
FACILITY
LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111
UNIVERSITY OF THE FOOT (2006)
PODIATRIST
SL56, MD
AM111111111

Type of Adverse Action: PROFESSIONAL SOCIETY
Basis for Action: CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR REVOKED BY
ANOTHER HOSPITAL OR HEALTH CARE FACILITY (A8)
Adverse Action
Classification Code(s): REVOCATION OF PROFESSIONAL SOCIETY MEMBERSHIP (1710)
Date Action Was Taken: 11/25/2014
Date Action Became Effective: 11/25/2014
Length of Action: PERMANENT
Description of Subject's Act(s) or Omission(s) or Other

C. INFORMATION
REPORTED

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960756
Process Date: 11/25/2014
Page: 2
of
2
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: BAD FOOT CARE.

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:
Date of Original Submission:

11/25/2014

Date of Most Recent Change:

11/25/2014

This report is maintained under the provisions of: Title IV
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Title IV of Public Law 99-660, as amended, 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