Basic Information
| Provider Information | |||||||||
| NPI: | 1053612697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKNEY | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1845 HWY 59 S, STE 800 - ALTRU CLINIC THIEF RIVER FALLS | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567014336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186817280 | ||||||||
| FaxNumber: | 2186835227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2010 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0910261 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP2597 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.