Provider Demographics
NPI:1760052310
Name:HAAG, JOANNA KAE (PMHNP)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:KAE
Last Name:HAAG
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:KAE
Other - Last Name:HILDEBRANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6805 IL 162
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-5019
Mailing Address - Fax:
Practice Address - Street 1:6805 STATE ROUTE 162 STE 201
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8530
Practice Address - Country:US
Practice Address - Phone:618-288-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021032483363LP0808X
390200000X
IL209027119363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program