Provider Demographics
NPI:1134817828
Name:FOLLBAUM, HALEY
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:FOLLBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9787
Mailing Address - Country:US
Mailing Address - Phone:734-552-1861
Mailing Address - Fax:
Practice Address - Street 1:21401 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1665
Practice Address - Country:US
Practice Address - Phone:734-675-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant