Provider Demographics
NPI:1538482773
Name:MANLEY, EDDIE A (APRN)
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:A
Last Name:MANLEY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:EDDIE
Other - Middle Name:A
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 1371
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-1371
Mailing Address - Country:US
Mailing Address - Phone:931-302-9564
Mailing Address - Fax:844-750-0655
Practice Address - Street 1:175 STATELINE RD
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262-8288
Practice Address - Country:US
Practice Address - Phone:931-302-9564
Practice Address - Fax:844-750-0655
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006470363L00000X, 363LF0000X
TN15072363L00000X
NC5005075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN15072OtherTENNESSE LICENSE NUMBER APRN
KY3006470OtherKY APRN LICENSE NUMBER
KY7100138050Medicaid
NC5005075OtherNC APRN LICENSE NUMBER