Provider Demographics
NPI:1982365557
Name:BACK, HALEY SUE (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:HALEY
Middle Name:SUE
Last Name:BACK
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:SUE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:601 DOE RUN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-8880
Mailing Address - Country:US
Mailing Address - Phone:859-432-3055
Mailing Address - Fax:859-432-3044
Practice Address - Street 1:601 DOE RUN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-8880
Practice Address - Country:US
Practice Address - Phone:859-432-3055
Practice Address - Fax:859-432-3044
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2024-07-19
Deactivation Date:2024-07-02
Deactivation Code:
Reactivation Date:2024-07-19
Provider Licenses
StateLicense IDTaxonomies
KY1167776163W00000X
KY4023046363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse