Provider Demographics
NPI:1215047782
Name:HANNEKEN, KIMBERLEY A (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
Last Name:HANNEKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HOSPITAL DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4568
Mailing Address - Country:US
Mailing Address - Phone:707-463-7488
Mailing Address - Fax:707-462-7846
Practice Address - Street 1:260 HOSPITAL DR
Practice Address - Street 2:SUITE 209
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4568
Practice Address - Country:US
Practice Address - Phone:707-463-7488
Practice Address - Fax:707-462-7846
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094217207QA0505X
CAG136098207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043486731OtherHEALTH ALLIANCE
IL036094217Medicaid
IL216239OtherMEDICARE GROUP PTAN
IL1326041229OtherMEDICARE GROUP NPI
IL216239OtherMEDICARE GROUP PTAN