Provider Demographics
NPI:1992763536
Name:HANNEMANN, STACY L (OT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:HANNEMANN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:10573 N FRIAR DR APT A
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8507
Mailing Address - Country:US
Mailing Address - Phone:661-373-1118
Mailing Address - Fax:
Practice Address - Street 1:10573 N FRIAR DR APT A
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8507
Practice Address - Country:US
Practice Address - Phone:661-373-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1767225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW0T1786AMedicare ID - Type Unspecified