Provider Demographics
NPI:1568035012
Name:HASELTON, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:HASELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:HEMINGWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:256 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:CHATEAUGAY
Mailing Address - State:NY
Mailing Address - Zip Code:12920-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 SHARRON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-4700
Practice Address - Country:US
Practice Address - Phone:518-561-1447
Practice Address - Fax:518-562-8812
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY788446163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid