MEDICARE: AMANDA HACKEMACK APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	3012653	KY

General Provider Information

NPI Number	:	1942770235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA HACKEMACK APRN

Provider Business Mailing Address
First Line	:	2700 STANLEY GAULT PKWY STE 129
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5176
Country	:	US
Telephone Number	:	502-253-4917
Fax Number	:	502-489-5751

Provider Business Practice Location Address
First Line	:	2315 GREEN VALLEY RD STE 100
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4690
Country	:	US
Telephone Number	:	812-945-2100
Fax Number	:	812-945-9495

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2018
Last Update Date	:	12/03/2020

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