Healthcare Provider Details

I. General information

NPI: 1396594727
Provider Name (Legal Business Name): ALEXANDRIA LYNN MANNS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

23318 MIMI ST
JERSEYVILLE IL
62052-6218
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax:
Mailing address:
  • Phone: 618-946-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2026026555
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2022002605
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209036086
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041575499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: