Healthcare Provider Details

I. General information

NPI: 1275109662
Provider Name (Legal Business Name): BRIAN LEE HANNIBAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W GARLAND AVE
SPOKANE WA
99205-2956
US

IV. Provider business mailing address

32832 N 14TH AVE
SPIRIT LAKE ID
83869-7718
US

V. Phone/Fax

Practice location:
  • Phone: 509-209-9488
  • Fax:
Mailing address:
  • Phone: 208-640-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161663014
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: