Provider Demographics
NPI:1972959187
Name:MANIS, AUDREY (MT-BC)
Entity Type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:
Last Name:MANIS
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 SAINT JAMES CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-2145
Mailing Address - Country:US
Mailing Address - Phone:931-581-2129
Mailing Address - Fax:
Practice Address - Street 1:1205 APPLEGATE LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-9608
Practice Address - Country:US
Practice Address - Phone:812-283-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist