Provider Demographics
NPI:1437509312
Name:LEE, MANERVIA
Entity Type:Individual
Prefix:
First Name:MANERVIA
Middle Name:
Last Name:LEE
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 1:1058 RIDGEWOOD PL STE G
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2002
Mailing Address - Country:US
Mailing Address - Phone:601-809-9222
Mailing Address - Fax:
Practice Address - Street 1:1058 RIDGEWOOD PL STE G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2002
Practice Address - Country:US
Practice Address - Phone:601-809-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS865836163WA2000X, 163WC0400X, 163WH0200X
MS326285164W00000X
171M00000X, 172V00000X, 174400000X, 174H00000X, 372600000X, 373H00000X, 376J00000X
MS36693374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide