Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN11888 | FL |
NPI | 1710953765 |
---|---|
Provider Name | Dr. Tara T Hackney |
First Address | Macclenny, FL 32063-2664 |
Second Address | Macclenny, FL 32063-2664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2006 |
Last Update Date | 23/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
071984601 | (05) | FL |