Provider Demographics
NPI:1912539941
Name:MANNEL, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MANNEL
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 1:1225 W PANORAMA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 W PANORAMA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-2834
Practice Address - Country:US
Practice Address - Phone:520-235-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH6043385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6043OtherAZ DEPT OF HEALTH SERVICES