Provider Demographics
NPI:1396198479
Name:HANNA, MARY (NP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HANNA
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3628
Mailing Address - Country:US
Mailing Address - Phone:888-223-1207
Mailing Address - Fax:
Practice Address - Street 1:32144 AGOURA RD STE 112
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4043
Practice Address - Country:US
Practice Address - Phone:818-208-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006242363LP2300X
MA2299223363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care