Provider Demographics
NPI:1093459521
Name:HAYNES, KEITH JUSTIN (NP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JUSTIN
Last Name:HAYNES
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 1:241 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3642
Mailing Address - Country:US
Mailing Address - Phone:540-250-4611
Mailing Address - Fax:
Practice Address - Street 1:43 PINNACLE DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2448
Practice Address - Country:US
Practice Address - Phone:540-245-7262
Practice Address - Fax:540-245-7054
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182258363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care