Provider Demographics
NPI:1992207534
Name:HAVERTY, PATRICIA JEAN (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:HAVERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1024
Mailing Address - Country:US
Mailing Address - Phone:313-802-5115
Mailing Address - Fax:
Practice Address - Street 1:9009 GRAYTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1900
Practice Address - Country:US
Practice Address - Phone:313-469-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704284652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner