Provider Demographics
NPI:1326041492
Name:HACKETT, CAROLYN K (NP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:K
Last Name:HACKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S UNION BLVD
Mailing Address - Street 2:SUITE # 350
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3113
Mailing Address - Country:US
Mailing Address - Phone:719-633-5515
Mailing Address - Fax:719-471-2258
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:SUITE # 350
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3113
Practice Address - Country:US
Practice Address - Phone:719-633-5515
Practice Address - Fax:719-471-2258
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO56351363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC200498Medicare PIN
COS33432Medicare UPIN
COP00429527Medicare PIN