Provider Demographics
NPI:1164931622
Name:MERTZ, HALEY (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:MERTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:CABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1107 MEMORIAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-275-6121
Mailing Address - Fax:706-275-0521
Practice Address - Street 1:1107 MEMORIAL DR STE 102
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-275-6121
Practice Address - Fax:706-275-0521
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008491OtherLICENSE