Provider Demographics
NPI:1629376405
Name:HANNELE LAINE, MD, PC
Entity Type:Organization
Organization Name:HANNELE LAINE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-355-9951
Mailing Address - Street 1:455 E SOUTH TEMPLE
Mailing Address - Street 2:STE 202
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1350
Mailing Address - Country:US
Mailing Address - Phone:801-355-9951
Mailing Address - Fax:801-355-9968
Practice Address - Street 1:455 E SOUTH TEMPLE
Practice Address - Street 2:STE 202
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84111-1350
Practice Address - Country:US
Practice Address - Phone:801-355-9951
Practice Address - Fax:801-355-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57672111205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty