Provider Demographics
NPI:1164021721
Name:MANNING, MISTIE SUE (NP-C)
Entity Type:Individual
Prefix:
First Name:MISTIE
Middle Name:SUE
Last Name:MANNING
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR STE 370
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7675
Mailing Address - Country:US
Mailing Address - Phone:801-747-7244
Mailing Address - Fax:
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR STE 370
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7675
Practice Address - Country:US
Practice Address - Phone:801-747-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6926945-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily