1407977887 NPI number — MS. DONNA RAE MANLEY PNP

Table of content: MS. DONNA RAE MANLEY PNP (NPI 1407977887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407977887 NPI number — MS. DONNA RAE MANLEY PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANLEY
Provider First Name:
DONNA
Provider Middle Name:
RAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407977887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CHILDRENS PL
Provider Second Line Business Mailing Address:
MSC 8515-87-1200
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-454-2694
Provider Business Mailing Address Fax Number:
314-454-2515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS PL
Provider Second Line Business Practice Location Address:
DIV PED ALLERGY/IMMUNO/PULMO
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-454-2694
Provider Business Practice Location Address Fax Number:
314-454-2515
Provider Enumeration Date:
04/03/2007

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:  115307 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 115307 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 424022903 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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