Provider Demographics
NPI:1245935113
Name:HAGGERTY, SEAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:HAGGERTY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W CASTRO DR
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3366
Mailing Address - Country:US
Mailing Address - Phone:208-906-4073
Mailing Address - Fax:
Practice Address - Street 1:1318 W CASTRO DR
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-3366
Practice Address - Country:US
Practice Address - Phone:307-220-4071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56647363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty