Individual
KIMBERLY N HACKNEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
300 WINDING WOODS DR STE 120, O FALLON, MO 63366-4772
(636) 978-7902
Mailing address
300 WINDING WOODS DR STE 120, O FALLON, MO 63366-4772
(636) 978-7902
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
2010037113
MO
2080P0204X
Pediatric Emergency Medicine (Pediatrics) Physician
05-35901
KS
2080P0204X
Pediatric Emergency Medicine (Pediatrics) Physician
2010037113
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1083842454
—
MO
01
—
P01296531
RAILROAD MEDICARE
MO
01
—
PAYEE 1
ILLINOIS MEDICAL ASSISTANCE PROGRAM
IL
Enumeration date
06/24/2009
Last updated
11/28/2017
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