Healthcare Provider Details

I. General information

NPI: 1588575906
Provider Name (Legal Business Name): VANESSA HAAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

14580 CREEK CLUB DR
MILTON GA
30004-4300
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0211
  • Fax:
Mailing address:
  • Phone: 470-222-9208
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: