Provider Demographics
NPI:1346248754
Name:HANISCH, ELLEN M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:M
Last Name:HANISCH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:HAGEMEIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1624 SOUTH I STREET
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5093
Mailing Address - Country:US
Mailing Address - Phone:253-428-8700
Mailing Address - Fax:253-383-3376
Practice Address - Street 1:11511 CANTERWOOD BLVD
Practice Address - Street 2:SUITE 45
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5813
Practice Address - Country:US
Practice Address - Phone:253-858-4725
Practice Address - Fax:253-858-4452
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-108210363L00000X
NE110748363L00000X
WAAP60134362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33314OtherWELLMARK
IA0421586Medicaid
IA0421586Medicaid
IAI8655Medicare ID - Type Unspecified