Provider Demographics
NPI:1245728567
Name:GOSVENER, HALEY DAWN
Entity type:Individual
Prefix:MS
First Name:HALEY
Middle Name:DAWN
Last Name:GOSVENER
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 1:5013 PEABODY RD # A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-8907
Mailing Address - Country:US
Mailing Address - Phone:707-208-4604
Mailing Address - Fax:
Practice Address - Street 1:1234 EMPIRE ST STE 2200
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5711
Practice Address - Country:US
Practice Address - Phone:707-648-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA692481164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA164X00000XMedicaid