Provider Demographics
NPI:1417527136
Name:MANLY, AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MANLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3243
Mailing Address - Country:US
Mailing Address - Phone:248-872-2970
Mailing Address - Fax:
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:248-872-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351048699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine