Healthcare Provider Details

I. General information

NPI: 1518653369
Provider Name (Legal Business Name): HALEY CELESTE CRAIG-KOVACH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19475 OLD JETTON RD STE 200
CORNELIUS NC
28031-6591
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1775
  • Fax: 704-384-1776
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024-02584
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRTL23-0923
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2024-02584
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: