Basic Information
| Provider Information | |||||||||
| NPI: | 1780057919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAVERKOST | ||||||||
| FirstName: | LEANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HARVEY | ||||||||
| OtherFirstName: | LEANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2015 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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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 | 363LF0000X | AP130721 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 390200000X | RN0000179744 | TN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.