Provider Demographics
NPI:1407694375
Name:HAVEN, CHASTIDY (FNP)
Entity type:Individual
Prefix:
First Name:CHASTIDY
Middle Name:
Last Name:HAVEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S WALNUT STREET PIKE APT B158
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7369
Mailing Address - Country:US
Mailing Address - Phone:812-322-4979
Mailing Address - Fax:
Practice Address - Street 1:308 W PIKE AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8755
Practice Address - Country:US
Practice Address - Phone:812-354-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169520A363L00000X
IN71015638A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner