Healthcare Provider Details

I. General information

NPI: 1558195081
Provider Name (Legal Business Name): HALEY GLASSY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PL STE 400
VANCOUVER WA
98664-3290
US

IV. Provider business mailing address

222 SE 8TH AVE STE 551
HILLSBORO OR
97123-4218
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-4444
  • Fax: 360-514-6530
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61605283
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: