Provider Demographics
NPI:1760562078
Name:MANATT, COURTNEY B (APN)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:B
Last Name:MANATT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:615 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-2507
Practice Address - Country:US
Practice Address - Phone:870-734-1150
Practice Address - Fax:870-347-3492
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01569 ANP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175922758Medicaid
AR56965Medicare PIN
ARCN2572Medicare PIN
AR57297Medicare PIN
AR175922758Medicaid