Provider Demographics
NPI:1790760825
Name:MANN, PHYLLIS MARY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:MARY
Last Name:MANN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 ROZAR GOOLSBY RD
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-2225
Mailing Address - Country:US
Mailing Address - Phone:478-374-2743
Mailing Address - Fax:
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-272-6509
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN018687164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse