Provider Demographics
NPI:1922117555
Name:MANNON, KORI R (MPT)
Entity Type:Individual
Prefix:MS
First Name:KORI
Middle Name:R
Last Name:MANNON
Suffix:
Gender:F
Credentials:MPT
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 477
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:NM
Mailing Address - Zip Code:88042-0477
Mailing Address - Country:US
Mailing Address - Phone:575-740-0356
Mailing Address - Fax:
Practice Address - Street 1:18 VALENCIA RD
Practice Address - Street 2:
Practice Address - City:ARROYO SECO
Practice Address - State:NM
Practice Address - Zip Code:87529-8752
Practice Address - Country:US
Practice Address - Phone:575-740-0356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM249328201Medicare PIN