Healthcare Provider Details

I. General information

NPI: 1376796771
Provider Name (Legal Business Name): JEFFERY LYNN MANNING F-NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1396 N 4800 W
PLAIN CITY UT
84404-9489
US

IV. Provider business mailing address

1396 N 4800 W
PLAIN CITY UT
84404-9489
US

V. Phone/Fax

Practice location:
  • Phone: 801-731-7227
  • Fax:
Mailing address:
  • Phone: 801-731-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5074276-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: