Healthcare Provider Details

I. General information

NPI: 1609563782
Provider Name (Legal Business Name): KAITLYND NICOLE HANNA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 PARK AVENUE DR. STE. B
LORAIN OH
44053-4153
US

IV. Provider business mailing address

2000 AUBURN DR. STE. 350
BEACHWOOD OH
44122-4327
US

V. Phone/Fax

Practice location:
  • Phone: 440-984-6499
  • Fax: 234-757-7545
Mailing address:
  • Phone: 440-646-1600
  • Fax: 440-646-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008429RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: