Provider Demographics
NPI:1194151423
Name:HANNER, TINA GAYLE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:GAYLE
Last Name:HANNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:BLDG. 4, STE 6
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3011
Practice Address - Country:US
Practice Address - Phone:903-342-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-066OtherTRICARE
TX75-2771569-005OtherTRICARE
TXP01280555OtherRAIL ROAD
TX75-2616977-043OtherTRICARE
TXP01812452OtherRAIL ROAD MEDICARE
TX328273302Medicaid
TX8583NDOtherBCBS
TX328273301Medicaid
TX8638MCOtherBCBS
TX75-2616977-066OtherTRICARE
TX325349YN3XMedicare PIN