Provider Demographics
NPI:1689453656
Name:PICKETT, HALEY MARIE PEACE (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:MARIE PEACE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 MILLICENT WAY APT 1505
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2264
Mailing Address - Country:US
Mailing Address - Phone:318-344-5035
Mailing Address - Fax:
Practice Address - Street 1:705 E MARSHALL AVE STE 1002
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5660
Practice Address - Country:US
Practice Address - Phone:903-759-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant