Basic Information
Provider Information | |||||||||
NPI: | 1194017624 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAYCRAFT | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 125 THISSEN CT STE 1600 | ||||||||
Address2: |   | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560015578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4802069477 | ||||||||
FaxNumber: | 6022628890 | ||||||||
Practice Location | |||||||||
Address1: | SOUTH CENTRAL HUMAN RELATIONS CENTER | ||||||||
Address2: | 610 FLORENCE AVE | ||||||||
City: | OWATONNA | ||||||||
State: | MN | ||||||||
PostalCode: | 55060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5074512630 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2011 | ||||||||
LastUpdateDate: | 02/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP3999 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 608 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 4981882917 | 01 | MN | PECOS | OTHER |