MEDICARE: MISTY MANUEL

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	363LP2300X	Primary Care Nurse Practitioner	APRN.CNP.026127	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APRN.CNP.026127	OTHER	OH	APRN LICENSE

General Provider Information

NPI Number	:	1811536378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY MANUEL

Provider Business Mailing Address
First Line	:	998 S DORSET RD STE 301
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-4748
Country	:	US
Telephone Number	:	937-339-9865
Fax Number	:

Provider Business Practice Location Address
First Line	:	998 S DORSET RD STE 301
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-4748
Country	:	US
Telephone Number	:	937-339-9865
Fax Number	:

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

Provider Enumeration Date	:	01/02/2020
Last Update Date	:	01/02/2020

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Directions to “ MISTY MANUEL ” Practice Location

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