Healthcare Provider Details

I. General information

NPI: 1720672900
Provider Name (Legal Business Name): AMANDA MCMANNIS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2021
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-782-5664
  • Fax: 330-782-1610
Mailing address:
  • Phone: 330-782-5664
  • Fax: 330-782-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.128202-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: