Provider Demographics
NPI:1396036216
Name:HAYWOOD, NICOLE MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HAYWOOD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E CLAY AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-8936
Mailing Address - Country:US
Mailing Address - Phone:509-935-7303
Mailing Address - Fax:
Practice Address - Street 1:301 E CLAY AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-8936
Practice Address - Country:US
Practice Address - Phone:509-935-7303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60043243174400000X
OR13807174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist