MEDICARE: MR. EDDIE A MANLEY APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	3006470	KY
2	363L00000X	Nurse Practitioner	15072	TN
3	363L00000X	Nurse Practitioner	5005075	NC
4	363LF0000X	Family Nurse Practitioner	3006470	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15072	OTHER	TN	TENNESSE LICENSE NUMBER APRN
2	3006470	OTHER	KY	KY APRN LICENSE NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	5005075	OTHER	NC	NC APRN LICENSE NUMBER

General Provider Information

NPI Number	:	1538482773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDDIE A MANLEY APRN

Provider Business Mailing Address
First Line	:	PO BOX 1371
Second Line	:
City	:	HOPKINSVILLE
State	:	KY
Zip	:	42241-1371
Country	:	US
Telephone Number	:	931-302-9564
Fax Number	:	844-750-0655

Provider Business Practice Location Address
First Line	:	175 STATELINE RD
Second Line	:
City	:	OAK GROVE
State	:	KY
Zip	:	42262-8288
Country	:	US
Telephone Number	:	931-302-9564
Fax Number	:	844-750-0655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2010
Last Update Date	:	04/29/2018

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