Provider Demographics
NPI:1831699966
Name:HALEY, KEIANNA S (CNM)
Entity type:Individual
Prefix:MRS
First Name:KEIANNA
Middle Name:S
Last Name:HALEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6055 COURTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2361
Mailing Address - Country:US
Mailing Address - Phone:347-731-0787
Mailing Address - Fax:
Practice Address - Street 1:10692 MEDLOCK BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8497
Practice Address - Country:US
Practice Address - Phone:404-446-2497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACNM04739207VX0201X
GARN273633207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003201850Medicaid