Provider Demographics
NPI:1124354758
Name:HANEMANN, MARY LEE (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:HANEMANN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-1998
Mailing Address - Country:US
Mailing Address - Phone:985-778-0528
Mailing Address - Fax:
Practice Address - Street 1:1021 WHITETAIL DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-1998
Practice Address - Country:US
Practice Address - Phone:985-778-0528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN071661 AP03536364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical