Provider Demographics
NPI:1174096374
Name:OLIPHANT, HALEY
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:OLIPHANT
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:ARTHURDALE
Mailing Address - State:WV
Mailing Address - Zip Code:26520-0133
Mailing Address - Country:US
Mailing Address - Phone:757-647-8560
Mailing Address - Fax:
Practice Address - Street 1:901 Q ROAD
Practice Address - Street 2:
Practice Address - City:ARTHURDALE
Practice Address - State:WV
Practice Address - Zip Code:26520
Practice Address - Country:US
Practice Address - Phone:757-647-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer