Healthcare Provider Details

I. General information

NPI: 1104801828
Provider Name (Legal Business Name): MARY BARNETT HASELDEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 WADE HAMPTON BLVD STE 120
GREENVILLE SC
29609
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-5000
  • Fax:
Mailing address:
  • Phone: 864-797-6174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN 1306
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: