Provider Demographics
NPI:1972664662
Name:HANNIFIN, LISA (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:HANNIFIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21036 VINTAGE ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-3054
Mailing Address - Country:US
Mailing Address - Phone:818-437-5337
Mailing Address - Fax:
Practice Address - Street 1:21036 VINTAGE ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-3054
Practice Address - Country:US
Practice Address - Phone:818-437-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27439111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU87539Medicare UPIN