Provider Demographics
NPI:1902527542
Name:HAEFFELE, TAYLOR (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:HAEFFELE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6400
Mailing Address - Country:US
Mailing Address - Phone:630-305-5027
Mailing Address - Fax:
Practice Address - Street 1:852 S WEST ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6400
Practice Address - Country:US
Practice Address - Phone:630-305-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty