Provider Demographics
NPI:1053846832
Name:HAYNES, JULIE MARIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:HAYNES
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 1:7642 SUNNYBROOK LN SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9551
Mailing Address - Country:US
Mailing Address - Phone:503-580-1691
Mailing Address - Fax:
Practice Address - Street 1:890 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3905
Practice Address - Country:US
Practice Address - Phone:503-561-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0011984390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program