Provider Demographics
NPI:1063991289
Name:MANNING, ALYSSA LYNN
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:MANNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3402
Mailing Address - Country:US
Mailing Address - Phone:918-392-4685
Mailing Address - Fax:918-392-4693
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:191-839-2468
Practice Address - Fax:918-392-4693
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK121063367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse