Provider Demographics
NPI:1285658880
Name:HACK, HEATHER ANN (LDM, CPM)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:HACK
Suffix:
Gender:F
Credentials:LDM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 SE 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1414
Mailing Address - Country:US
Mailing Address - Phone:503-504-0885
Mailing Address - Fax:503-914-1862
Practice Address - Street 1:2620 SE 51ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1414
Practice Address - Country:US
Practice Address - Phone:503-504-0885
Practice Address - Fax:503-914-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LM-1008799176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife