Provider Demographics
NPI:1508914219
Name:HAYNES, MICHEALLE ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHEALLE
Middle Name:ANN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 WEST BOULEVARD
Mailing Address - Street 2:PO BOX 69
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 WEST BOULEVARD
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352
Practice Address - Country:US
Practice Address - Phone:910-277-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753328Medicare ID - Type Unspecified
NCP49343Medicare UPIN