Provider Demographics
NPI:1992536403
Name:DETILLIER, HAILEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:MARIE
Last Name:DETILLIER
Suffix:
Gender:F
Credentials:PA-C
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 1125
Mailing Address - Street 2:
Mailing Address - City:GRAMERCY
Mailing Address - State:LA
Mailing Address - Zip Code:70052-1125
Mailing Address - Country:US
Mailing Address - Phone:225-348-7120
Mailing Address - Fax:
Practice Address - Street 1:15813 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1426
Practice Address - Country:US
Practice Address - Phone:985-230-6278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant