Provider Demographics
NPI:1710242771
Name:HACKWORTH, SHANA L
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:HACKWORTH
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 1:800 E LEXINGTON AVE
Mailing Address - Street 2:SUITE # 114
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-4713
Mailing Address - Country:US
Mailing Address - Phone:619-275-8000
Mailing Address - Fax:
Practice Address - Street 1:1675 MORENA BLVD
Practice Address - Street 2:STE. #100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3703
Practice Address - Country:US
Practice Address - Phone:619-275-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator