1063164622 NPI number — ASHLEY BROOKE HACKWORTH MEDICAL STUDENT

Table of content: ASHLEY BROOKE HACKWORTH MEDICAL STUDENT (NPI 1063164622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063164622 NPI number — ASHLEY BROOKE HACKWORTH MEDICAL STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKWORTH
Provider First Name:
ASHLEY
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL STUDENT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063164622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1348 SW 2ND CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33312-7593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
636-357-6719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1348 SW 2ND CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33312-7593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-357-6719
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com