Healthcare Provider Details

I. General information

NPI: 1023724655
Provider Name (Legal Business Name): HALEIGH K POE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3542 WESTERN AVE STE B
CONNERSVILLE IN
47331-3504
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-7858
  • Fax: 765-827-7859
Mailing address:
  • Phone: 765-935-8802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003923A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: