Provider Demographics
NPI:1164188090
Name:HACKLEY, KEANU IRENE
Entity Type:Individual
Prefix:
First Name:KEANU
Middle Name:IRENE
Last Name:HACKLEY
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 1:4717 CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2420
Mailing Address - Country:US
Mailing Address - Phone:502-554-0380
Mailing Address - Fax:
Practice Address - Street 1:204 E MARKET ST # A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1218
Practice Address - Country:US
Practice Address - Phone:502-588-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program