Provider Demographics
NPI:1487315420
Name:WILLOUGHBY, HAILEY (FNP-C)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 LAPEER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4480
Mailing Address - Country:US
Mailing Address - Phone:810-650-0644
Mailing Address - Fax:
Practice Address - Street 1:1210 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3406
Practice Address - Country:US
Practice Address - Phone:810-662-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278139363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily