Provider Demographics
NPI:1013461276
Name:MANNING, BLAYNE
Entity Type:Individual
Prefix:
First Name:BLAYNE
Middle Name:
Last Name:MANNING
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 1:225 COMMUNITY DR
Mailing Address - Street 2:#110
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 COMMUNITY DR
Practice Address - Street 2:#110
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5503
Practice Address - Country:US
Practice Address - Phone:516-918-4388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307828363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health