Basic Information
| Provider Information | |||||||||
| NPI: | 1790730794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAUGE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | HUBERTZ | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUBERTZ | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232832 | ||||||||
| FaxNumber: | 7722235665 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SE OSCEOLA ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722861550 | ||||||||
| FaxNumber: | 7722210569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2999642 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | Y063E | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 013012400 | 05 | FL | MEDICAID |