Provider Demographics
NPI:1508115007
Name:HACK, KRISTIE (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:1532 LONE OAK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7942
Practice Address - Country:US
Practice Address - Phone:270-443-0777
Practice Address - Fax:270-443-0999
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100275470Medicaid
KYK122860Medicare PIN