Provider Demographics
NPI:1619590874
Name:HAEFNER, ANDREA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:HAEFNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7660 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1723
Mailing Address - Country:US
Mailing Address - Phone:585-943-5755
Mailing Address - Fax:
Practice Address - Street 1:7660 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1723
Practice Address - Country:US
Practice Address - Phone:585-943-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682879-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse