Healthcare Provider Details

I. General information

NPI: 1932452299
Provider Name (Legal Business Name): HALEY HALLEMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6291 MAIN ST
BONNERS FERRY ID
83805-8518
US

IV. Provider business mailing address

PO BOX V
BONNERS FERRY ID
83805-1286
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-0134
  • Fax: 208-561-7865
Mailing address:
  • Phone: 208-267-0134
  • Fax: 208-561-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1391
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA1391
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: