Healthcare Provider Details

I. General information

NPI: 1245758739
Provider Name (Legal Business Name): HALEY HANI DICKOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

IV. Provider business mailing address

PO BOX 23321
NEW YORK NY
10087-4321
US

V. Phone/Fax

Practice location:
  • Phone: 216-477-0017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5334
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601008291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: