Healthcare Provider Details

I. General information

NPI: 1154929651
Provider Name (Legal Business Name): SHAUNTEL EVETTE HAAS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 3215 BOX MDG
APO AE
09094-3215
US

IV. Provider business mailing address

2811 TOLAND DR
FAIRFIELD CA
94534-3441
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2609
  • Fax:
Mailing address:
  • Phone: 208-867-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number34580
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number75677
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: