Provider Demographics
NPI:1679660294
Name:CARROLL-HACK, KATHLEEN JUDITH (PNP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:JUDITH
Last Name:CARROLL-HACK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:JUDITH
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 ORRINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1623
Mailing Address - Country:US
Mailing Address - Phone:916-419-5319
Mailing Address - Fax:
Practice Address - Street 1:7275 E SOUTHGATE DR
Practice Address - Street 2:SUITE 306
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2628
Practice Address - Country:US
Practice Address - Phone:916-422-6635
Practice Address - Fax:916-422-2741
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13696363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics