Provider Demographics
NPI:1043629819
Name:MANNING, KRISTA LOUISE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LOUISE
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:PO BOX 584
Mailing Address - Street 2:
Mailing Address - City:BIG PINEY
Mailing Address - State:WY
Mailing Address - Zip Code:83113
Mailing Address - Country:US
Mailing Address - Phone:847-707-6727
Mailing Address - Fax:
Practice Address - Street 1:450 SUNSHINE DR.
Practice Address - Street 2:
Practice Address - City:BIG PINEY
Practice Address - State:WY
Practice Address - Zip Code:83113
Practice Address - Country:US
Practice Address - Phone:847-707-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14175890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist