Provider Demographics
NPI:1689306052
Name:WANIC, HALEY NICOLE (DNP, A-GNP)
Entity Type:Individual
Prefix:DR
First Name:HALEY
Middle Name:NICOLE
Last Name:WANIC
Suffix:
Gender:F
Credentials:DNP, A-GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14165 N FENTON RD STE 201A
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1584
Mailing Address - Country:US
Mailing Address - Phone:108-535-8758
Mailing Address - Fax:
Practice Address - Street 1:14165 N FENTON RD STE 201A
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1584
Practice Address - Country:US
Practice Address - Phone:810-853-5875
Practice Address - Fax:586-279-4515
Is Sole Proprietor?:No
Enumeration Date:2022-06-25
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704356520363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner