Basic Information
| Provider Information | |||||||||
| NPI: | 1003803792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAACKE | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013876150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 W 1700 S | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840166004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014164474 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2043174405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.