Healthcare Provider Details

I. General information

NPI: 1174073050
Provider Name (Legal Business Name): MARY JANE HANNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MJ HANNAN

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 TRACY RD STE 660
NEW WHITELAND IN
46184-9100
US

IV. Provider business mailing address

570 TRACY RD STE 660
NEW WHITELAND IN
46184-9100
US

V. Phone/Fax

Practice location:
  • Phone: 317-530-2541
  • Fax: 317-454-1392
Mailing address:
  • Phone: 317-530-2541
  • Fax: 317-454-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: