Provider Demographics
NPI:1518722982
Name:HAYNES, ANNIE MAE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:MAE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:MAE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JACKSON
Mailing Address - Street 1:2610 SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-1540
Mailing Address - Country:US
Mailing Address - Phone:314-495-1611
Mailing Address - Fax:
Practice Address - Street 1:2610 SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1540
Practice Address - Country:US
Practice Address - Phone:314-495-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108121376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty