Healthcare Provider Details

I. General information

NPI: 1114367182
Provider Name (Legal Business Name): MRS. AMANDA MANNO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. AMANDA FANNING

II. Dates (important events)

Enumeration Date: 07/04/2013
Last Update Date: 11/03/2023
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MACOMB ST
MONROE MI
48162-7815
US

IV. Provider business mailing address

375 RIVER ST
MANISTEE MI
49660-2729
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-5238
  • Fax: 734-240-2573
Mailing address:
  • Phone: 231-398-1957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number195903-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704263072
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: