Healthcare Provider Details

I. General information

NPI: 1316488836
Provider Name (Legal Business Name): MARY JANE MCMANUS PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 HIGHWAY 17 S STE 3
NORTH MYRTLE BEACH SC
29582-4391
US

IV. Provider business mailing address

630 CHESTNUT RD
MYRTLE BEACH SC
29572-5502
US

V. Phone/Fax

Practice location:
  • Phone: 843-491-3344
  • Fax: 843-491-3399
Mailing address:
  • Phone: 843-945-1452
  • Fax: 843-945-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21348
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21348
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: