Healthcare Provider Details

I. General information

NPI: 1992956395
Provider Name (Legal Business Name): KATHLEEN MARIE MANNION
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4252
US

IV. Provider business mailing address

3599 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4252
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-7643
  • Fax:
Mailing address:
  • Phone: 904-858-7643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number2102
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: