Provider Demographics
NPI:1861684649
Name:MCMANNIS, LYNN W (RN)
Entity type:Individual
Prefix:MR
First Name:LYNN
Middle Name:W
Last Name:MCMANNIS
Suffix:
Gender:M
Credentials:RN
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 4174
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14852
Mailing Address - Country:US
Mailing Address - Phone:607-279-2874
Mailing Address - Fax:
Practice Address - Street 1:141 W HILL CIRCLE
Practice Address - Street 2:APT 7
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-257-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3367991163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02109002Medicaid