Provider Demographics
NPI:1548681430
Name:HANNIFIN, ALICE (NP-C)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:
Last Name:HANNIFIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8500
Mailing Address - Fax:901-260-8598
Practice Address - Street 1:2569 DOUGLASS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-2532
Practice Address - Country:US
Practice Address - Phone:901-701-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ003427Medicaid