Provider Demographics
NPI:1104193176
Name:HAYNES, LETHA
Entity Type:Individual
Prefix:
First Name:LETHA
Middle Name:
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 1:948 CAMBRIDGE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3647
Mailing Address - Country:US
Mailing Address - Phone:954-492-7150
Mailing Address - Fax:
Practice Address - Street 1:948 CAMBRIDGE DR STE 102
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3647
Practice Address - Country:US
Practice Address - Phone:985-652-7717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LART0004241207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2138910Medicaid