Healthcare Provider Details

I. General information

NPI: 1902433469
Provider Name (Legal Business Name): JACQUELINE MARIE HALEY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

6025 ODELL ST
SAINT LOUIS MO
63139-2631
US

V. Phone/Fax

Practice location:
  • Phone: 314-550-0432
  • Fax:
Mailing address:
  • Phone: 314-550-0432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2019036526
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: