Provider Demographics
NPI:1336446202
Name:HANSON, SUSAN AMANDA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:AMANDA
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E UNIVERSITY
Mailing Address - Street 2:SLOT 36
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2181
Mailing Address - Country:US
Mailing Address - Phone:870-235-5254
Mailing Address - Fax:870-235-5263
Practice Address - Street 1:100 E UNIVERSITY
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2181
Practice Address - Country:US
Practice Address - Phone:870-235-5254
Practice Address - Fax:870-235-5254
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR66906163W00000X
ARA004721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily