Healthcare Provider Details

I. General information

NPI: 1699171215
Provider Name (Legal Business Name): MARK ALAN MANNING DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SAGAMORE PKWY WEST
WEST LAFAYETTE IN
47906
US

IV. Provider business mailing address

124 SAGAMORE PKWY WEST
WEST LAFAYETTE IN
47906
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-6722
  • Fax: 765-463-0905
Mailing address:
  • Phone: 765-463-6722
  • Fax: 765-463-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71006259A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60520310
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: