Provider Demographics
NPI:1598349250
Name:HAINES, MARY KAY (RDH, BCTN, FDN-P)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:HAINES
Suffix:
Gender:F
Credentials:RDH, BCTN, FDN-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PARK ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2762
Mailing Address - Country:US
Mailing Address - Phone:248-722-2412
Mailing Address - Fax:
Practice Address - Street 1:224 PARK ISLAND DR
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2762
Practice Address - Country:US
Practice Address - Phone:248-722-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI