Healthcare Provider Details

I. General information

NPI: 1043465206
Provider Name (Legal Business Name): KAREN MARIE HANNAH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE STE 102
PHOENIX AZ
85015-3211
US

IV. Provider business mailing address

5060 N 19TH AVE STE 102
PHOENIX AZ
85015-3211
US

V. Phone/Fax

Practice location:
  • Phone: 602-296-5540
  • Fax: 602-296-5442
Mailing address:
  • Phone: 602-296-5540
  • Fax: 602-296-5442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAP3208
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberAP3208
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberAP3208
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP3208
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: