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NPI Code Detail

MEDICARE: HALEY NYSTROM

MEDICARE: HALEY NYSTROM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer096.004687IL
22255A2300XAthletic Trainer
3390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1346769122
Entity Type Code : Individual
Provider Name (Legal Business Name) : HALEY NYSTROM
Provider Business Mailing Address
First Line : 347 HILLSIDE RD
Second Line :
City : NEW LENOX
State : IL
Zip : 60451-1619
Country : US
Telephone Number : 708-638-6504
Fax Number :
Provider Business Practice Location Address
First Line : 951 ESSINGTON RD
Second Line :
City : JOLIET
State : IL
Zip : 60435-8439
Country : US
Telephone Number : 708-638-6504
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/13/2017
Last Update Date : 09/28/2022

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Directions to “ HALEY NYSTROM ” Practice Location

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