Provider Demographics
NPI:1003140195
Name:HAYNES, KATHERINE ANN (RN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:675 SOUTH 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-2776
Mailing Address - Country:US
Mailing Address - Phone:541-914-1829
Mailing Address - Fax:541-942-9022
Practice Address - Street 1:675 SOUTH 14TH STREET
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2776
Practice Address - Country:US
Practice Address - Phone:541-914-1829
Practice Address - Fax:541-942-9022
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095000628RN163W00000X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500611115Medicaid