1790730794 NPI number — DIANE HUBERTZ HAUGE ARNP

Table of content: DIANE HUBERTZ HAUGE ARNP (NPI 1790730794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790730794 NPI number — DIANE HUBERTZ HAUGE ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAUGE
Provider First Name:
DIANE
Provider Middle Name:
HUBERTZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUBERTZ
Provider Other First Name:
DIANE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790730794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34995-0417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-223-2832
Provider Business Mailing Address Fax Number:
772-223-5665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 SE OSCEOLA ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-286-1550
Provider Business Practice Location Address Fax Number:
772-221-0569
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  ARNP2999642 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y063E . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 013012400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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