Provider Demographics
NPI:1144239021
Name:HAYWALD, JERRY R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:R
Last Name:HAYWALD
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
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Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5000
Mailing Address - Fax:
Practice Address - Street 1:HUNTER HOLMS MCQUIRE VETERANS
Practice Address - Street 2:1201 BROAD ROCK BLV
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024167059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144239021Medicaid