Healthcare Provider Details

I. General information

NPI: 1053226977
Provider Name (Legal Business Name): HALEY OTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N. 3RD STREET HEALTH NORTH BUILDING, 3RD FLOOR
PHOENIX AZ
85004
US

IV. Provider business mailing address

550 N. 3RD STREET HEALTH NORTH BUILDING, 3RD FLOOR
PHOENIX AZ
85004
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: