Provider Demographics
NPI:1356735971
Name:KALLASH, HANAN (FNP)
Entity type:Individual
Prefix:
First Name:HANAN
Middle Name:
Last Name:KALLASH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 FIESTA DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-1876
Mailing Address - Country:US
Mailing Address - Phone:410-419-9184
Mailing Address - Fax:
Practice Address - Street 1:10 EAST WILSON BLVD
Practice Address - Street 2:MINUTE CLINIC
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:410-419-9184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001498363LF0000X
VA0024172402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVI727E533Medicare PIN