Healthcare Provider Details

I. General information

NPI: 1952123390
Provider Name (Legal Business Name): JOHANN ALEXANDER HAIDACHER APRN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 SW OTTER RUN PL
STUART FL
34997
US

IV. Provider business mailing address

296 SW OTTER RUN PL
STUART FL
34997
US

V. Phone/Fax

Practice location:
  • Phone: 954-394-4118
  • Fax:
Mailing address:
  • Phone: 954-394-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11036185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: