Provider Demographics
NPI:1801927280
Name:HANIG, PHYLLIS TENENBAUM (ARNP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:TENENBAUM
Last Name:HANIG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PHYLLISFELICIA
Other - Middle Name:T
Other - Last Name:HANIG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:1603 COOPER POINT RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8325
Mailing Address - Country:US
Mailing Address - Phone:360-451-1841
Mailing Address - Fax:360-754-0666
Practice Address - Street 1:1603 COOPER POINT RD NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8325
Practice Address - Country:US
Practice Address - Phone:360-451-1841
Practice Address - Fax:360-754-0666
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002431363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9607417Medicaid
WA9607417Medicaid
WAAB04261Medicare ID - Type Unspecified