Provider Demographics
NPI:1104796077
Name:TRUCKENBROD, HANNAH
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:TRUCKENBROD
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 5213
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60204-5213
Mailing Address - Country:US
Mailing Address - Phone:847-565-6412
Mailing Address - Fax:224-714-1740
Practice Address - Street 1:1854 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3795
Practice Address - Country:US
Practice Address - Phone:847-565-6412
Practice Address - Fax:224-714-1740
Is Sole Proprietor?:No
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program