Healthcare Provider Details

I. General information

NPI: 1811816192
Provider Name (Legal Business Name): MS. ANDREA ANN HAYLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOMER ST
STATEN ISLAND NY
10301-3101
US

IV. Provider business mailing address

3 HOMER ST
STATEN ISLAND NY
10301-3101
US

V. Phone/Fax

Practice location:
  • Phone: 646-251-9287
  • Fax:
Mailing address:
  • Phone: 646-251-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number375780
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: