Provider Demographics
NPI:1104401405
Name:HANNING, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:HANNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:25039-0545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BIG MT ROAD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:WV
Practice Address - Zip Code:25039
Practice Address - Country:US
Practice Address - Phone:681-254-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker