Provider Demographics
NPI:1518307024
Name:MANN, BETSY L (FNP)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:L
Last Name:MANN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SELA
Other - Middle Name:ELIZABETH
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:1106 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-8972
Practice Address - Country:US
Practice Address - Phone:601-656-6921
Practice Address - Fax:601-656-0381
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07388396Medicaid
MS303288YJ8JMedicare PIN