1538482773 NPI number — MR. EDDIE A MANLEY APRN

Table of content: MR. EDDIE A MANLEY APRN (NPI 1538482773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538482773 NPI number — MR. EDDIE A MANLEY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANLEY
Provider First Name:
EDDIE
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANLEY
Provider Other First Name:
EDDIE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1538482773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42241-1371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-302-9564
Provider Business Mailing Address Fax Number:
844-750-0655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 STATELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK GROVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42262-8288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-302-9564
Provider Business Practice Location Address Fax Number:
844-750-0655
Provider Enumeration Date:
03/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  3006470 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 15072 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 5005075 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 3006470 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15072 . This is a "TENNESSE LICENSE NUMBER APRN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3006470 . This is a "KY APRN LICENSE NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100138050 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5005075 . This is a "NC APRN LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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