=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104454768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALEY C RICHARDSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 SPRING ST
-----------------------------------------------------
City | JEFFERSONVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47130-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-282-8494
-----------------------------------------------------
Fax | 812-288-4481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776351
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-588-9490
-----------------------------------------------------
Fax | 502-272-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | TC165
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10003008A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------