Provider Demographics
NPI:1619499241
Name:HANNAH-LYON, RAE LEEN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:LEEN
Last Name:HANNAH-LYON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:RAE
Other - Middle Name:LEEN
Other - Last Name:HANNAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1412 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7639
Mailing Address - Country:US
Mailing Address - Phone:817-702-3431
Mailing Address - Fax:817-927-3603
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134481363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care