Provider Demographics
NPI:1346591815
Name:HAINES, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:HAINES
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 1:3170 KETTERING BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:122 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2731
Practice Address - Country:US
Practice Address - Phone:937-223-4461
Practice Address - Fax:937-449-7603
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13356-NP363LF0000X
OHAPRN.CNP13356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294150Medicaid