Provider Demographics
NPI:1104977495
Name:HAEFNER, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:HAEFNER
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 1:38252 SARNETTE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036
Mailing Address - Country:US
Mailing Address - Phone:586-954-9042
Mailing Address - Fax:
Practice Address - Street 1:38242 SARNETTE ST
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-4038
Practice Address - Country:US
Practice Address - Phone:586-954-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210354363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health