Healthcare Provider Details

I. General information

NPI: 1356512883
Provider Name (Legal Business Name): VIVIAN N HANNON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4258 HIGHWAY 231
LACEYS SPRING AL
35754-6448
US

IV. Provider business mailing address

1241 BLOUNT AVE
GUNTERSVILLE AL
35976-1831
US

V. Phone/Fax

Practice location:
  • Phone: 256-498-5770
  • Fax:
Mailing address:
  • Phone: 256-582-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-057030
License Number StateAL

VIII. Authorized Official

Name: MR. MARK CHRISTOPHER HANNON
Title or Position: OFFICE MANAGER
Credential:
Phone: 256-498-5770