Provider Demographics
NPI:1063585248
Name:HALEY, GLYNNIS J (NP-C)
Entity type:Individual
Prefix:
First Name:GLYNNIS
Middle Name:J
Last Name:HALEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:250 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-301-4111
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000934304CMedicaid
GA500025995OtherRAILROAD MEDICARE
GAP463434Medicare ID - Type Unspecified
GA50BBGFBMedicare PIN