Basic Information
| Provider Information | |||||||||
| NPI: | 1649491432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 NORTH MAYSVILLE STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT. STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8592740785 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 NORTH MAYSVILLE STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT. STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8592740785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 3004121 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 11981709 | 01 | CAQH # | OTHER | 9100649 | 01 | AETNA | OTHER | 7100045030 | 05 | KY | MEDICAID | 000000671076 | 01 | ANTHEM BCBS | OTHER |