Provider Demographics
NPI:1326577354
Name:HAYNES, REBECCA L (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:HAYNES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DRIVE MAILBOX 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3404
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2838
Is Sole Proprietor?:No
Enumeration Date:2017-06-04
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161494A363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health