Provider Demographics
NPI:1659571198
Name:HANNA, JACQUELINE M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:M
Last Name:HANNA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601549
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1549
Mailing Address - Country:US
Mailing Address - Phone:704-384-4274
Mailing Address - Fax:704-384-5636
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4274
Practice Address - Fax:704-384-5636
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC077461367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN806Medicaid
NC8052983Medicaid
NC8052983Medicaid