Provider Demographics
NPI:1376040741
Name:HANSON, MURNA M
Entity Type:Individual
Prefix:MISS
First Name:MURNA
Middle Name:M
Last Name:HANSON
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 1:29 PRINCE JOHN LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7165
Mailing Address - Country:US
Mailing Address - Phone:386-246-0828
Mailing Address - Fax:
Practice Address - Street 1:29 PRINCE JOHN LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7165
Practice Address - Country:US
Practice Address - Phone:386-246-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12522310400000X
AL11336310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid