Provider Demographics
NPI:1407977887
Name:MANLEY, DONNA RAE (PNP)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:RAE
Last Name:MANLEY
Suffix:
Gender:F
Credentials:PNP
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Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:MSC 8515-87-1200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-2694
Mailing Address - Fax:314-454-2515
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED ALLERGY/IMMUNO/PULMO
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-2694
Practice Address - Fax:314-454-2515
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO115307363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424022903Medicaid
MO1407977887Medicaid