Provider Demographics
NPI:1780149153
Name:MANLEY, SHANNON LYN (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYN
Last Name:MANLEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5352
Practice Address - Country:US
Practice Address - Phone:415-432-7899
Practice Address - Fax:510-899-7101
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010607363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner