Provider Demographics
NPI:1407141856
Name:HANSEN, HOLLI LEANNA (NP-C)
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:LEANNA
Last Name:HANSEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:HOLLI
Other - Middle Name:LEANNA
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:1090 W PARK PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-215-2005
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1009A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1407141856Medicaid
IDNP-1009AOtherSTATE LICENSE
IDP00954635OtherMEDICARE RAILROAD CARRIER
IDP00954635OtherMEDICARE RAILROAD CARRIER