Basic Information
| Provider Information | |||||||||
| NPI: | 1114976073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNINO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JEANETTE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34940 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033722740 | ||||||||
| FaxNumber: | 5033722754 | ||||||||
| Practice Location | |||||||||
| Address1: | 26701 CROWN VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495821090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 773 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 277677 | CA | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | RN2776770 | 05 | CA | MEDICAID |