Provider Demographics
NPI:1598049728
Name:SMITH, HALEY DIANA (RN, NP-C)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:DIANA
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:802 AVENUE J
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5125
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX724898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0016SHOtherBCBS
TXD07564OtherPALMETTO RR
TXP01005507OtherPALMETTO RR
TX2035487-01Medicaid
TX865N94OtherBCBS
TX2874786-01Medicaid
TXTXB142570Medicare PIN
TXP01005507OtherPALMETTO RR