Healthcare Provider Details

I. General information

NPI: 1154339935
Provider Name (Legal Business Name): LAURA A HANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8988 E US HIGHWAY 20
NEW CARLISLE IN
46552-9038
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 574-654-7779
  • Fax: 574-654-7780
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061101A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: