Healthcare Provider Details

I. General information

NPI: 1003803792
Provider Name (Legal Business Name): CYNTHIA L. HAACKE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W 1700 S
CLEARFIELD UT
84016-6004
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-416-4474
  • Fax:
Mailing address:
  • Phone: 801-387-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2043174405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: