Provider Demographics
NPI:1467101436
Name:DUBOSE, HALEY A (NP)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:A
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:A
Other - Last Name:ALLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1575 N RIVERCENTER DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3978
Mailing Address - Country:US
Mailing Address - Phone:414-283-8444
Mailing Address - Fax:
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3978
Practice Address - Country:US
Practice Address - Phone:414-283-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11448-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100198471Medicaid