Healthcare Provider Details

I. General information

NPI: 1760491641
Provider Name (Legal Business Name): KATHRYN L HACKMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BRANSON LANDING BLVD SUITE 100
BRANSON MO
65616
US

IV. Provider business mailing address

545 BRANSON LANDING BLVD SUITE 100
BRANSON MO
65616
US

V. Phone/Fax

Practice location:
  • Phone: 417-335-7587
  • Fax: 417-335-7529
Mailing address:
  • Phone: 417-335-7587
  • Fax: 417-335-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number113135
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number113135
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: