Provider Demographics
NPI:1669644738
Name:MERRILL, HAILEE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:HAILEE
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 VALLEY VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6342
Mailing Address - Country:US
Mailing Address - Phone:814-946-5469
Mailing Address - Fax:814-946-4970
Practice Address - Street 1:810 VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6342
Practice Address - Country:US
Practice Address - Phone:814-946-5469
Practice Address - Fax:814-946-4970
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033035420001Medicaid