Provider Demographics
NPI:1407099336
Name:HAIES, JILLIAN FAYE (ANP,WHNP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:FAYE
Last Name:HAIES
Suffix:
Gender:F
Credentials:ANP,WHNP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:FAYE
Other - Last Name:GROVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP, WHNP
Mailing Address - Street 1:801 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5752
Practice Address - Country:US
Practice Address - Phone:212-749-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305063363LA2200X
NYF420913363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid