Provider Demographics
NPI:1033800123
Name:HACKETT, MYKEELA
Entity Type:Individual
Prefix:
First Name:MYKEELA
Middle Name:
Last Name:HACKETT
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 1:2668 WARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2668 WARD LAKE RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1738
Practice Address - Country:US
Practice Address - Phone:678-251-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1246451343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)