Healthcare Provider Details

I. General information

NPI: 1205790938
Provider Name (Legal Business Name): ANDREA HACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 S 8TH ST
NEDERLAND TX
77627-2635
US

IV. Provider business mailing address

713 S 8TH ST
NEDERLAND TX
77627-2635
US

V. Phone/Fax

Practice location:
  • Phone: 304-566-9262
  • Fax:
Mailing address:
  • Phone: 304-566-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number1168087
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: