Healthcare Provider Details

I. General information

NPI: 1598565780
Provider Name (Legal Business Name): PHYLLIS MANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER ST
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

10343 GRAND CLUB DR
SAN ANTONIO TX
78239-1416
US

V. Phone/Fax

Practice location:
  • Phone: 210-452-5476
  • Fax:
Mailing address:
  • Phone: 210-617-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number694389
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: