Provider Demographics
NPI:1114324829
Name:HANSON, LUCILLE LYDA (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LUCILLE
Middle Name:LYDA
Last Name:HANSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 N CLARKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1765
Mailing Address - Country:US
Mailing Address - Phone:218-296-0384
Mailing Address - Fax:315-425-2653
Practice Address - Street 1:201 MARKET ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1278
Practice Address - Country:US
Practice Address - Phone:315-274-7003
Practice Address - Fax:315-425-2653
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR186310-7363LP0808X
NY402614363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health