Provider Demographics
NPI:1639166176
Name:HACKNEY, KATHRYN P (PAC)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:P
Last Name:HACKNEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:N
Other - Last Name:PRIVETTE HACKNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:237 PROFESSIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-4404
Mailing Address - Country:US
Mailing Address - Phone:360-426-2500
Mailing Address - Fax:360-462-2500
Practice Address - Street 1:237 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4404
Practice Address - Country:US
Practice Address - Phone:360-426-2500
Practice Address - Fax:360-462-2500
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004637363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8402349Medicaid