Provider Demographics
NPI:1720277601
Name:HACKMAN, DONNA (NP-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:HACKMAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:104 NICHOLAS PLACE
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710
Practice Address - Country:US
Practice Address - Phone:260-897-3308
Practice Address - Fax:260-897-3650
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002502A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000549136OtherANTHEM
IN000000528690OtherANTHEM
IN200879960Medicaid
IN000000548973OtherANTHEM
INP00478527OtherRAILROAD MEDICARE
IN200879960Medicaid
IN250260DMedicare PIN