Provider Demographics
NPI:1083842454
Name:HACKNEY, KIMBERLY N (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:HACKNEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:N
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:300 WINDING WOODS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-4772
Mailing Address - Country:US
Mailing Address - Phone:636-978-7902
Mailing Address - Fax:
Practice Address - Street 1:300 WINDING WOODS DR STE 120
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-4772
Practice Address - Country:US
Practice Address - Phone:636-978-7902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100371132080P0204X, 208000000X
KS05-359012080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01296531OtherRAILROAD MEDICARE
ILPAYEE 1OtherILLINOIS MEDICAL ASSISTANCE PROGRAM
MO1083842454Medicaid
ILPAYEE 1OtherILLINOIS MEDICAL ASSISTANCE PROGRAM