Provider Demographics
NPI:1891982906
Name:HANBY, JENNIFER DAIGLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAIGLE
Last Name:HANBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:DAIGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1136 E GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3982
Mailing Address - Country:US
Mailing Address - Phone:903-592-5601
Mailing Address - Fax:
Practice Address - Street 1:1136 E GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3982
Practice Address - Country:US
Practice Address - Phone:903-592-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2327207Y00000X
LAMD.200387207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063592Medicaid
LA4N258CA42Medicare PIN