Healthcare Provider Details

I. General information

NPI: 1700233855
Provider Name (Legal Business Name): DEBRA HAFER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33290 CHINCOTEAGUE RD
WALLOPS ISLAND VA
23337-2204
US

IV. Provider business mailing address

33290 CHINCOTEAGUE RD
WALLOPS ISLAND VA
23337-2204
US

V. Phone/Fax

Practice location:
  • Phone: 703-463-6190
  • Fax:
Mailing address:
  • Phone: 703-463-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0001145188
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: