Basic Information
| Provider Information | |||||||||
| NPI: | 1265981476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON HAVEN | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30532 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325031532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504793320 | ||||||||
| FaxNumber: | 8504798789 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 UNIVERSITY PKWY STE 309 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325145485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504793320 | ||||||||
| FaxNumber: | 8504798789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9110516 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.