Provider Demographics
NPI:1023497591
Name:MANION, GAYLIN (FNP)
Entity type:Individual
Prefix:
First Name:GAYLIN
Middle Name:
Last Name:MANION
Suffix:
Gender:F
Credentials:FNP
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 419059
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9059
Mailing Address - Country:US
Mailing Address - Phone:618-207-6900
Mailing Address - Fax:618-207-6901
Practice Address - Street 1:1167 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7377
Practice Address - Country:US
Practice Address - Phone:618-207-6900
Practice Address - Fax:618-207-6901
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400230847Medicare PIN