Provider Demographics
NPI:1598402760
Name:SOUTHWICK, HALEY K
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:K
Last Name:SOUTHWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N LOIS AVE UNIT 151
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2353
Mailing Address - Country:US
Mailing Address - Phone:702-285-3418
Mailing Address - Fax:
Practice Address - Street 1:10040 ALTA DR STE 100B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8630
Practice Address - Country:US
Practice Address - Phone:702-960-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV871230363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care