Provider Demographics
NPI:1770830960
Name:HAVERSTICK, DEWAYNE CARL (NREMTP)
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:CARL
Last Name:HAVERSTICK
Suffix:
Gender:M
Credentials:NREMTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S SPRINGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-5060
Mailing Address - Country:US
Mailing Address - Phone:251-518-9110
Mailing Address - Fax:
Practice Address - Street 1:453 SOUTH NOVACEL DR
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:251-518-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0800200146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic