Provider Demographics
NPI:1952123390
Name:HAIDACHER, JOHANN ALEXANDER (APRN FNP)
Entity type:Individual
Prefix:
First Name:JOHANN
Middle Name:ALEXANDER
Last Name:HAIDACHER
Suffix:
Gender:M
Credentials:APRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 SW OTTER RUN PL
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997
Mailing Address - Country:US
Mailing Address - Phone:954-394-4118
Mailing Address - Fax:
Practice Address - Street 1:296 SW OTTER RUN PL
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997
Practice Address - Country:US
Practice Address - Phone:954-394-4118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty