1346248754 NPI number — MS. ELLEN M HANISCH NURSE PRACTITIONER

Table of content: MS. ELLEN M HANISCH NURSE PRACTITIONER (NPI 1346248754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346248754 NPI number — MS. ELLEN M HANISCH NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANISCH
Provider First Name:
ELLEN
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAGEMEIER
Provider Other First Name:
ELLEN
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1346248754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 SOUTH I STREET
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-5093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-428-8700
Provider Business Mailing Address Fax Number:
253-383-3376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11511 CANTERWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 45
Provider Business Practice Location Address City Name:
GIG HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98332-5813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-858-4725
Provider Business Practice Location Address Fax Number:
253-858-4452
Provider Enumeration Date:
07/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  A-108210 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 110748 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: AP60134362 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33314 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0421586 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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