Provider Demographics
NPI:1659543643
Name:HANLEY, WILLIAM (NP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:HANLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:STE 502
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1075
Practice Address - Country:US
Practice Address - Phone:574-647-5875
Practice Address - Fax:574-647-5878
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006238A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201258990Medicaid
IN000001014258OtherANTHEM