Provider Demographics
NPI:1326371287
Name:HACKER, TAMMY LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LYNN
Last Name:HACKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 357
Mailing Address - Street 2:134 JASMINE LANE
Mailing Address - City:STINNET
Mailing Address - State:KY
Mailing Address - Zip Code:40868
Mailing Address - Country:US
Mailing Address - Phone:606-598-4506
Mailing Address - Fax:606-598-1027
Practice Address - Street 1:210 MARIE LANGDON DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6388
Practice Address - Country:US
Practice Address - Phone:606-598-4506
Practice Address - Fax:606-598-1027
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01004431Medicaid
KY1811922347Medicare PIN