Provider Demographics
NPI:1174864656
Name:MANN, CATHY GAYLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:GAYLE
Last Name:MANN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9260
Mailing Address - Country:US
Mailing Address - Phone:843-234-8260
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-234-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006106363LF0000X
SC20244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4065Medicaid