Provider Demographics
NPI:1255922753
Name:HAACKER, KRISTIN MARY
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARY
Last Name:HAACKER
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 1:120 NORTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-3048
Mailing Address - Country:US
Mailing Address - Phone:585-491-0374
Mailing Address - Fax:
Practice Address - Street 1:120 NORTHGATE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3048
Practice Address - Country:US
Practice Address - Phone:585-491-0374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309450164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY309450OtherSTATE NURSING LICENSE