Provider Demographics
NPI:1730703240
Name:MANNING, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
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 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2621 GREENHAVEN RD
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-5566
Practice Address - Country:US
Practice Address - Phone:763-587-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-31
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2116688163WX0002X
MN480367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2116688OtherRN NUMBER