Basic Information
| Provider Information | |||||||||
| NPI: | 1154339935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 KELLE DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463048708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262312 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Practice Location | |||||||||
| Address1: | 8988 E US HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | NEW CARLISLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465529038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746547779 | ||||||||
| FaxNumber: | 5746547780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01061101A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000378303 | 01 | IN | ANTHEM, BCBS | OTHER | 200529120A | 05 | IN | MEDICAID |