Provider Demographics
NPI:1801540034
Name:BYWATERS, HALEY ANNE (NP)
Entity type:Individual
Prefix:MRS
First Name:HALEY
Middle Name:ANNE
Last Name:BYWATERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:ANNE
Other - Last Name:DEAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-647-1100
Practice Address - Fax:574-647-5907
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704393582363LF0000X
IN71012499A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801540034Medicaid
IN300066388Medicaid