Provider Demographics
NPI:1558897363
Name:KING, HANNA MAE
Entity Type:Individual
Prefix:
First Name:HANNA
Middle Name:MAE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANNA
Other - Middle Name:MAE
Other - Last Name:RAHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:145 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3724
Mailing Address - Country:US
Mailing Address - Phone:860-347-0720
Mailing Address - Fax:
Practice Address - Street 1:145 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3724
Practice Address - Country:US
Practice Address - Phone:860-347-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69282207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program