Provider Demographics
NPI:1407445059
Name:HACK, CANDACE MARTINA (APRN)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARTINA
Last Name:HACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ELK FORK RD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-7218
Mailing Address - Country:US
Mailing Address - Phone:270-265-2574
Mailing Address - Fax:
Practice Address - Street 1:1739 CANTON ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1991
Practice Address - Country:US
Practice Address - Phone:270-881-1411
Practice Address - Fax:270-886-6008
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015668363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health