Provider Demographics
NPI:1801225503
Name:MOMMY'S MANNA, PLLC
Entity Type:Organization
Organization Name:MOMMY'S MANNA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIETRA
Authorized Official - Middle Name:RA'CHEL
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, IBCLC
Authorized Official - Phone:336-392-5384
Mailing Address - Street 1:205 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6352
Mailing Address - Country:US
Mailing Address - Phone:336-392-5384
Mailing Address - Fax:
Practice Address - Street 1:205 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6352
Practice Address - Country:US
Practice Address - Phone:336-392-5384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL-47283163WL0100X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty