Provider Demographics
NPI:1366221368
Name:HACKWORTH, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HACKWORTH
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 1:3536 W FENCHURCH RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3615
Mailing Address - Country:US
Mailing Address - Phone:801-707-6842
Mailing Address - Fax:
Practice Address - Street 1:201 PRESIDENTS CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9049
Practice Address - Country:US
Practice Address - Phone:801-585-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program