Provider Demographics
NPI:1275943292
Name:HANNES, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HANNES
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:BLDG 301 ANDREWS AVENUE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7033
Mailing Address - Fax:
Practice Address - Street 1:BLDG 301 ANDREWS AVENUE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-142923163W00000X
GARN215194163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse