Healthcare Provider Details

I. General information

NPI: 1134990187
Provider Name (Legal Business Name): MRS. AMANDA MANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 410
GLENDALE AZ
85308-8732
US

IV. Provider business mailing address

1118 N VILLA NUEVA DR
LITCHFIELD PARK AZ
85340-4527
US

V. Phone/Fax

Practice location:
  • Phone: 623-800-7980
  • Fax:
Mailing address:
  • Phone: 602-677-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: