Basic Information
Provider Information | |||||||||
NPI: | 1316930779 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANAWALT | ||||||||
FirstName: | CINDY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 905 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507034407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192724300 | ||||||||
FaxNumber: | 3192724411 | ||||||||
Practice Location | |||||||||
Address1: | 1570 42ND ST NE STE 1 | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524023073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192004400 | ||||||||
FaxNumber: | 3192004401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 05/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34383 | IA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4212837 | 05 | IA |   | MEDICAID | 15689 | 01 | IA | WELLMARK BCBS OF IOWA | OTHER | 0076372 | 05 | IA |   | MEDICAID |