Healthcare Provider Details

I. General information

NPI: 1366996886
Provider Name (Legal Business Name): AMY LEE MANNING FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 HIGHWAY Y
ELLINGTON MO
63638-7802
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-663-2525
  • Fax: 573-663-7821
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016025943
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: