Healthcare Provider Details

I. General information

NPI: 1588964100
Provider Name (Legal Business Name): ELIZABETH ANN HANNA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2481 N 72ND AVE
HART MI
49420-8008
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-2163
  • Fax: 231-873-2143
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704201363
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: