Provider Demographics
NPI:1053395152
Name:HAINES, VICKI A (NP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:A
Last Name:HAINES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-738-0647
Mailing Address - Fax:315-738-9719
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-738-0647
Practice Address - Fax:315-738-9719
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300033-1363LA2200X
NYF360102-1363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP25727Medicare UPIN