Healthcare Provider Details

I. General information

NPI: 1215047782
Provider Name (Legal Business Name): KIMBERLEY A HANNEKEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR SUITE 209
UKIAH CA
95482-4568
US

IV. Provider business mailing address

260 HOSPITAL DR SUITE 209
UKIAH CA
95482-4568
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-7488
  • Fax: 707-462-7846
Mailing address:
  • Phone: 707-463-7488
  • Fax: 707-462-7846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036094217
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG136098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: