Provider Demographics
NPI:1619416443
Name:HACK, CHARLOTTE LYNN
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:LYNN
Last Name:HACK
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 1:6538 MARKET ST.
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-549-9699
Mailing Address - Fax:330-549-0383
Practice Address - Street 1:12236 MARKET ST
Practice Address - Street 2:
Practice Address - City:NORTH LIMA
Practice Address - State:OH
Practice Address - Zip Code:44452-9770
Practice Address - Country:US
Practice Address - Phone:330-718-6698
Practice Address - Fax:330-549-0383
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401815311215376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0203879Medicaid