Provider Demographics
NPI:1699082651
Name:MANFREDI, MIA S (ARNP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:S
Last Name:MANFREDI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 N CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-6634
Mailing Address - Country:US
Mailing Address - Phone:316-686-6671
Mailing Address - Fax:316-686-1094
Practice Address - Street 1:415 N POPLAR AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4529
Practice Address - Country:US
Practice Address - Phone:316-686-6671
Practice Address - Fax:316-686-1094
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75238-052363LF0000X, 364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily