Healthcare Provider Details

I. General information

NPI: 1659975381
Provider Name (Legal Business Name): HAILEY HOVELSRUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9085 E MOUNTAIN VIEW RD
PRESCOTT VALLEY AZ
86315-4181
US

IV. Provider business mailing address

9085 E MOUNTAIN VIEW RD
PRESCOTT VALLEY AZ
86315-4181
US

V. Phone/Fax

Practice location:
  • Phone: 928-499-7066
  • Fax:
Mailing address:
  • Phone: 928-499-7066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-04212
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: