=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780149153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON LYN MANLEY FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2019
-----------------------------------------------------
Last Update Date | 02/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 PIEDMONT AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-5352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-432-7899
-----------------------------------------------------
Fax | 510-899-7101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-7956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95010607
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------