Healthcare Provider Details

I. General information

NPI: 1467447169
Provider Name (Legal Business Name): SHANE NELSON MANNING D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 01/07/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY KAISER PERMANENTE GLENLAKE
ATLANTA GA
30328-3473
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 620-662-6000
  • Fax: 620-669-2394
Mailing address:
  • Phone: 404-365-0966
  • Fax: 620-669-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001087A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003364M
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001209
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: