Healthcare Provider Details

I. General information

NPI: 1114842200
Provider Name (Legal Business Name): HEATHER LILYANN MANHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER LILYANN LARSEN

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 SONOMA HWY STE B
SANTA ROSA CA
95409-4165
US

IV. Provider business mailing address

4415 SONOMA HWY STE B
SANTA ROSA CA
95409-4165
US

V. Phone/Fax

Practice location:
  • Phone: 530-921-3955
  • Fax:
Mailing address:
  • Phone: 707-470-4521
  • 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 StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: