Provider Demographics
NPI:1194117671
Name:MANTLE, DEANNA MARIE
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:MARIE
Last Name:MANTLE
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 1:1716 HIGHWAY C
Mailing Address - Street 2:
Mailing Address - City:BONNOTS MILL
Mailing Address - State:MO
Mailing Address - Zip Code:65016-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5581
Practice Address - Fax:573-632-5876
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily