Basic Information
| Provider Information | |||||||||
| NPI: | 1922541598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACKER | ||||||||
| FirstName: | TAMMIE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MEMORIAL DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065994080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2016 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3010683 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MH4559944 | 01 | KY | DEA | OTHER | 7100443670 | 05 | KY | MEDICAID | XH4559944 | 01 | KY | DEA | OTHER |