Provider Demographics
NPI:1184257206
Name:HALEY, LISA (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HALEY
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 1:311 N CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:CENTERBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43011-9739
Mailing Address - Country:US
Mailing Address - Phone:614-517-3603
Mailing Address - Fax:
Practice Address - Street 1:123 WESTERVILLE PLZ
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2882
Practice Address - Country:US
Practice Address - Phone:614-394-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0392784Medicaid