Basic Information
Provider Information | |||||||||
NPI: | 1962977389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANLEY | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANLEY | ||||||||
OtherFirstName: | KATIE | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 79 HIGHWAY 51 S | ||||||||
Address2: |   | ||||||||
City: | RIPLEY | ||||||||
State: | TN | ||||||||
PostalCode: | 380634580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316358189 | ||||||||
FaxNumber: | 7316358121 | ||||||||
Practice Location | |||||||||
Address1: | 79 HIGHWAY 51 S | ||||||||
Address2: |   | ||||||||
City: | RIPLEY | ||||||||
State: | TN | ||||||||
PostalCode: | 380634580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316358189 | ||||||||
FaxNumber: | 7316358121 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2018 | ||||||||
LastUpdateDate: | 07/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 24919 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.