Provider Demographics
NPI:1093049488
Name:HAYNES, TABITHA LYNN (FNP)
Entity Type:Individual
Prefix:MISS
First Name:TABITHA
Middle Name:LYNN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-3455
Mailing Address - Fax:321-434-3456
Practice Address - Street 1:1350 HICKORY ST STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-3455
Practice Address - Fax:321-434-3456
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10118363LF0000X
FLAPRN11004630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69704741Medicaid
FLRM791OtherHFMG MA
FL114683400Medicaid