Provider Demographics
NPI:1699711747
Name:HANNAN, STACEY MARIE (OD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:HANNAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 POST RD
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-3334
Mailing Address - Country:US
Mailing Address - Phone:724-612-3943
Mailing Address - Fax:
Practice Address - Street 1:2010 VILLAGE CENTER DR
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:TARENTUM
Practice Address - State:PA
Practice Address - Zip Code:15084-3844
Practice Address - Country:US
Practice Address - Phone:724-274-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001285152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1594678OtherHIGHMARK BC/BS
PA1009498450001Medicaid
PA075259SBZMedicare PIN
PA1594678OtherHIGHMARK BC/BS