1215047782 NPI number — KIMBERLEY A HANNEKEN MD

Table of content: KIMBERLEY A HANNEKEN MD (NPI 1215047782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215047782 NPI number — KIMBERLEY A HANNEKEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANNEKEN
Provider First Name:
KIMBERLEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215047782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
UKIAH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95482-4568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-463-7488
Provider Business Mailing Address Fax Number:
707-462-7846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-4568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-463-7488
Provider Business Practice Location Address Fax Number:
707-462-7846
Provider Enumeration Date:
08/30/2006

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: 207QA0505X , with the licence number:  036094217 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0505X , with the licence number: G136098 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1043486731 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036094217 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 216239 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1326041229 . This is a "MEDICARE GROUP NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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