Provider Demographics
NPI:1871185496
Name:SMALLWOOD, HALEY (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:SMALLWOOD
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 1:806 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3734
Mailing Address - Country:US
Mailing Address - Phone:937-405-9391
Mailing Address - Fax:
Practice Address - Street 1:444 E BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3708
Practice Address - Country:US
Practice Address - Phone:914-200-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant