Provider Demographics
NPI:1346220191
Name:HANNON, VIVIAN NELL
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:NELL
Last Name:HANNON
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 1:354 CARDESSA LN
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:AL
Mailing Address - Zip Code:35747-9222
Mailing Address - Country:US
Mailing Address - Phone:256-728-2330
Mailing Address - Fax:256-582-6376
Practice Address - Street 1:1241 BLOUNT AVE
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-1831
Practice Address - Country:US
Practice Address - Phone:256-582-6377
Practice Address - Fax:256-582-6376
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1066616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051031359OtherBCBS OF AL
AL000031359Medicaid
AL000031359Medicaid
AL051031359OtherBCBS OF AL
AL000031359Medicare ID - Type UnspecifiedCRNP