Provider Demographics
NPI:1063457760
Name:HAVRILIAK, JACQUELINE M (CRNA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:HAVRILIAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CORLISS AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2060
Mailing Address - Country:US
Mailing Address - Phone:607-763-6735
Mailing Address - Fax:
Practice Address - Street 1:156 CORLISS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2060
Practice Address - Country:US
Practice Address - Phone:607-763-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN246320L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered