Provider Demographics
NPI:1114410446
Name:HAYNESWORTH, GLENA AFFLICK
Entity Type:Individual
Prefix:
First Name:GLENA
Middle Name:AFFLICK
Last Name:HAYNESWORTH
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 1:3615 GALLATIN ST APT 1124
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3936
Mailing Address - Country:US
Mailing Address - Phone:202-597-8279
Mailing Address - Fax:
Practice Address - Street 1:1707 L ST NW STE 900
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-4208
Practice Address - Country:US
Practice Address - Phone:202-867-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13506374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherHHA
NY$$$$$$$$$OtherNONE