Provider Demographics
NPI:1760491641
Name:HACKMAN, KATHRYN L (FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:HACKMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 BRANSON LANDING BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616
Mailing Address - Country:US
Mailing Address - Phone:417-335-7587
Mailing Address - Fax:417-335-7529
Practice Address - Street 1:545 BRANSON LANDING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616
Practice Address - Country:US
Practice Address - Phone:417-335-7587
Practice Address - Fax:417-335-7529
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113135163WX0106X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2578OtherCOX HEALTH SYSTEMS
P00365026OtherRAILROAD MEDICARE
250766OtherHEALTHLINK
126814OtherBCBS
MO428135354Medicaid
MO209396704Medicaid
MO209396704Medicaid