Provider Demographics
NPI:1659563112
Name:MANNING, GERVONIA
Entity Type:Individual
Prefix:MRS
First Name:GERVONIA
Middle Name:
Last Name:MANNING
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 1:13021 BLUES FARM RD
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-2517
Mailing Address - Country:US
Mailing Address - Phone:910-276-0487
Mailing Address - Fax:910-276-4123
Practice Address - Street 1:821 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4724
Practice Address - Country:US
Practice Address - Phone:910-276-0487
Practice Address - Fax:991-027-6412
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2538251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408009Medicaid