Provider Demographics
NPI:1962273490
Name:HACKENBURG, SALLY
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:HACKENBURG
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 1:719 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1426
Mailing Address - Country:US
Mailing Address - Phone:567-228-9956
Mailing Address - Fax:
Practice Address - Street 1:719 EVERETT RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1426
Practice Address - Country:US
Practice Address - Phone:567-228-9956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant