Provider Demographics
NPI:1588000111
Name:HACKETT, STEPHANIE (PA-C, MPH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HACKETT
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 SEMINOLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1418
Mailing Address - Country:US
Mailing Address - Phone:203-214-5551
Mailing Address - Fax:
Practice Address - Street 1:524 SEMINOLE AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1418
Practice Address - Country:US
Practice Address - Phone:203-214-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant