Provider Demographics
NPI:1255926556
Name:HANNA, KIMBERLY M (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:HANNA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-6478
Mailing Address - Country:US
Mailing Address - Phone:208-777-5418
Mailing Address - Fax:208-561-7077
Practice Address - Street 1:7850 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-6478
Practice Address - Country:US
Practice Address - Phone:208-777-5418
Practice Address - Fax:208-561-7077
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33924163W00000X
WARN00163840163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse