Healthcare Provider Details

I. General information

NPI: 1720778657
Provider Name (Legal Business Name): HAYLEY VANDERJAGT MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 TRAMWAY BLVD NE
ALBUQUERQUE NM
87112-4655
US

IV. Provider business mailing address

3124 COLORADO ST NE
ALBUQUERQUE NM
87110-2654
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: