Provider Demographics
NPI:1679606362
Name:MANNELLO, DONNA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:MARIE
Last Name:MANNELLO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W LOCKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2915
Mailing Address - Country:US
Mailing Address - Phone:314-962-6015
Mailing Address - Fax:314-962-7874
Practice Address - Street 1:113 W LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2915
Practice Address - Country:US
Practice Address - Phone:314-962-6015
Practice Address - Fax:314-962-7874
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005436111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
165692OtherGROUP HEALTH PLAN
MO9944OtherANTHEM BCBS
247468OtherHEALTHLINK HMO PPO
MO9944OtherANTHEM BCBS