Healthcare Provider Details

I. General information

NPI: 1619618519
Provider Name (Legal Business Name): HALEY MASHEA HERRIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW COMMERCE DR
LAKE CITY FL
32055-4709
US

IV. Provider business mailing address

148 SW BRANDY WAY
LAKE CITY FL
32024-4550
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9477310
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11021039
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: