Provider Demographics
NPI:1154757094
Name:HASELTINE, STEPHANIE LYNN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:HASELTINE
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:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:KLAWOCK
Mailing Address - State:AK
Mailing Address - Zip Code:99925-0484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MILE 12.7 KLAWOCK HOLLIS HWY
Practice Address - Street 2:
Practice Address - City:KLAWOCK
Practice Address - State:AK
Practice Address - Zip Code:99925
Practice Address - Country:US
Practice Address - Phone:888-609-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered