Provider Demographics
NPI:1578831350
Name:HACKER, MIRANDA RACHELLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RACHELLE
Last Name:HACKER
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 1:1601 E F ST LOT 78
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-2967
Mailing Address - Country:US
Mailing Address - Phone:307-575-1172
Mailing Address - Fax:
Practice Address - Street 1:2301 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-2621
Practice Address - Country:US
Practice Address - Phone:307-575-1172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator