Provider Demographics
NPI:1720025968
Name:HANNA, SHAHIRA (MD)
Entity type:Individual
Prefix:
First Name:SHAHIRA
Middle Name:
Last Name:HANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAHIRA
Other - Middle Name:H
Other - Last Name:KENEALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:1657 TRINITY DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5708
Practice Address - Country:US
Practice Address - Phone:850-416-2400
Practice Address - Fax:850-416-2330
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114485Medicaid
MS512I160034Medicare PIN
E12909Medicare UPIN
MS00114485Medicaid