Healthcare Provider Details

I. General information

NPI: 1487315420
Provider Name (Legal Business Name): HAILEY WILLOUGHBY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 10TH AVE
PORT HURON MI
48060-3406
US

IV. Provider business mailing address

812 LAPEER AVE STE B
PORT HURON MI
48060-4480
US

V. Phone/Fax

Practice location:
  • Phone: 810-662-3505
  • Fax:
Mailing address:
  • Phone: 810-650-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704278139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: