Provider Demographics
NPI:1912589870
Name:HALLER, MICHAELA LYNN
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LYNN
Last Name:HALLER
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 1:70 CONSTITUTION RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2038
Mailing Address - Country:US
Mailing Address - Phone:978-505-8628
Mailing Address - Fax:
Practice Address - Street 1:70 CONSTITUTION RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2038
Practice Address - Country:US
Practice Address - Phone:978-505-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant