Provider Demographics
NPI:1992869739
Name:HALEY, KATHLEEN MARIE (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:HALEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5100
Mailing Address - Country:US
Mailing Address - Phone:559-326-1222
Mailing Address - Fax:559-326-1230
Practice Address - Street 1:9850 GENESEE AVE STE 560
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1229
Practice Address - Country:US
Practice Address - Phone:858-552-1410
Practice Address - Fax:858-552-0929
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA287434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP05784Medicare UPIN