Provider Demographics
NPI:1669191953
Name:MANKA, ANNALYCE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ANNALYCE
Middle Name:
Last Name:MANKA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 BATTERY AVE SE UNIT 423
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8611 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4351
Practice Address - Country:US
Practice Address - Phone:623-939-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist