Provider Demographics
NPI:1720067879
Name:HAVILAND, DARLENE MARIE (PAC)
Entity Type:Individual
Prefix:MS
First Name:DARLENE
Middle Name:MARIE
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PINE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-2196
Mailing Address - Country:US
Mailing Address - Phone:508-832-9572
Mailing Address - Fax:508-832-4758
Practice Address - Street 1:113 ELM ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3700
Practice Address - Country:US
Practice Address - Phone:860-741-2225
Practice Address - Fax:860-741-2229
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290001494CT01OtherANTHEM BLUE CROSS
MAS17713Medicare UPIN