1639166176 NPI number — MS. KATHRYN P HACKNEY PAC

Table of content: MS. KATHRYN P HACKNEY PAC (NPI 1639166176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639166176 NPI number — MS. KATHRYN P HACKNEY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKNEY
Provider First Name:
KATHRYN
Provider Middle Name:
P
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRIVETTE HACKNEY
Provider Other First Name:
KATIE
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639166176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
237 PROFESSIONAL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98584-4404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-426-2500
Provider Business Mailing Address Fax Number:
360-462-2500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
237 PROFESSIONAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98584-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-426-2500
Provider Business Practice Location Address Fax Number:
360-462-2500
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA10004637 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8402349 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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