Provider Demographics
NPI:1811369010
Name:HACKER, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HACKER
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 1:18 DAFFODIL CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1642
Mailing Address - Country:US
Mailing Address - Phone:646-280-5111
Mailing Address - Fax:
Practice Address - Street 1:18 DAFFODIL CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1642
Practice Address - Country:US
Practice Address - Phone:646-280-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist