Provider Demographics
NPI:1417569229
Name:MANN, JEANETTE SYLVESTER
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:SYLVESTER
Last Name:MANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24426-6115
Mailing Address - Country:US
Mailing Address - Phone:540-998-0633
Mailing Address - Fax:
Practice Address - Street 1:25 COMMERCE PARK DR
Practice Address - Street 2:
Practice Address - City:RAPHINE
Practice Address - State:VA
Practice Address - Zip Code:24472-2547
Practice Address - Country:US
Practice Address - Phone:540-490-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily