Provider Demographics
NPI:1114367182
Name:MANNO, AMANDA
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MANNO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:FANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2729
Mailing Address - Country:US
Mailing Address - Phone:231-398-1957
Mailing Address - Fax:
Practice Address - Street 1:718 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7815
Practice Address - Country:US
Practice Address - Phone:734-240-5238
Practice Address - Fax:734-240-2573
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-04
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195903-30367500000X
MI4704263072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered