Provider Demographics
NPI:1578590097
Name:HAYNES-LEE, JOAN ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:ELAINE
Last Name:HAYNES-LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:ELAINE
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:FILE # 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-558-6600
Mailing Address - Fax:
Practice Address - Street 1:25455 BARTON RD STE 204B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3130
Practice Address - Country:US
Practice Address - Phone:909-558-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65038207Q00000X
CAC51704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C517040Medicaid
00C517040Medicare ID - Type Unspecified
CA00C517040Medicaid