=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114674926
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALEY BROOK LINN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2022
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1935 MEDICAL DISTRICT DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-456-2033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2321 HARTLINE DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-474-3017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PA15508
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------