Basic Information
| Provider Information | |||||||||
| NPI: | 1639166176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACKNEY | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRIVETTE HACKNEY | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 237 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985844404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262500 | ||||||||
| FaxNumber: | 3604622500 | ||||||||
| Practice Location | |||||||||
| Address1: | 237 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985844404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262500 | ||||||||
| FaxNumber: | 3604622500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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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 | 363AM0700X | PA10004637 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8402349 | 05 | WA | MEDICAID |