Provider Demographics
NPI:1881941748
Name:HACKER, MARY E (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:HACKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LITTLE SPRING RUN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3204
Mailing Address - Country:US
Mailing Address - Phone:585-248-8723
Mailing Address - Fax:
Practice Address - Street 1:34 LITTLE SPRING RUN
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3204
Practice Address - Country:US
Practice Address - Phone:585-248-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251E00000X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization