Provider Demographics
NPI:1447847389
Name:HAUBROCK, STEPHEN GLENN (NP)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GLENN
Last Name:HAUBROCK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6558 PARTRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7009
Mailing Address - Country:US
Mailing Address - Phone:513-560-6414
Mailing Address - Fax:513-682-4186
Practice Address - Street 1:2990 MACK RD STE 107
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5384
Practice Address - Country:US
Practice Address - Phone:513-860-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0027935363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner