Provider Demographics
NPI:1215504311
Name:HACKETT, CHARLYN SUE
Entity type:Individual
Prefix:
First Name:CHARLYN
Middle Name:SUE
Last Name:HACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14016 JOAN DR
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-3085
Mailing Address - Country:US
Mailing Address - Phone:870-818-0014
Mailing Address - Fax:
Practice Address - Street 1:402 S LEE ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:AR
Practice Address - Zip Code:71744-8615
Practice Address - Country:US
Practice Address - Phone:870-798-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily