Provider Demographics
NPI:1033691845
Name:HATHCOCK, DEBRA ANN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:HATHCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7825
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7825
Mailing Address - Country:US
Mailing Address - Phone:307-690-6505
Mailing Address - Fax:
Practice Address - Street 1:724 W SNOW KING AVE # 7825
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8498
Practice Address - Country:US
Practice Address - Phone:307-690-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator