Provider Demographics
NPI:1073855466
Name:HANNA, MICHELLE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:HANNA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 DEMPSTER ST
Mailing Address - Street 2:YACKTMAN PAVILION
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1110
Mailing Address - Country:US
Mailing Address - Phone:847-318-9300
Mailing Address - Fax:
Practice Address - Street 1:1675 DEMPSTER ST
Practice Address - Street 2:YACKTMAN PAVILION
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:847-318-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.140410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics