Provider Demographics
NPI:1619336930
Name:MANNON, JOANNA (ATC, SCAT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:MANNON
Suffix:
Gender:F
Credentials:ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HAY HILL LN UNIT A
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4292
Mailing Address - Country:US
Mailing Address - Phone:704-778-5612
Mailing Address - Fax:
Practice Address - Street 1:3302 ROBERT M GRISSOM PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-6401
Practice Address - Country:US
Practice Address - Phone:843-488-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1817247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other