Provider Demographics
NPI:1477720381
Name:HALEY, EVELYN (CNM)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 SE WILLOUGHBY BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-5060
Mailing Address - Country:US
Mailing Address - Phone:772-219-1223
Mailing Address - Fax:
Practice Address - Street 1:501 NW LAKE WHITNEY PL STE 106
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1615
Practice Address - Country:US
Practice Address - Phone:772-785-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56607163W00000X
WV111176B00000X
FL9313099367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003243400Medicaid