Healthcare Provider Details

I. General information

NPI: 1063761898
Provider Name (Legal Business Name): KRISTEN HEBERT HANNAMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 COUNTRY CLUB RD
LAKE CHARLES LA
70605-5203
US

IV. Provider business mailing address

10319 JEFFERSON HWY
BATON ROUGE LA
70809-2730
US

V. Phone/Fax

Practice location:
  • Phone: 337-990-8000
  • Fax: 337-990-8010
Mailing address:
  • Phone: 225-214-9352
  • Fax: 225-214-9349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number782
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: