Provider Demographics
NPI:1205316221
Name:HAVENS, MADELINE CHASTAIN
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:CHASTAIN
Last Name:HAVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7332
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-2067
Practice Address - Street 1:1222 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7332
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-2067
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-09-24
Deactivation Date:2018-08-30
Deactivation Code:
Reactivation Date:2018-09-12
Provider Licenses
StateLicense IDTaxonomies
NC5010948363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner