Provider Demographics
NPI:1619311438
Name:HAYNIE, AMANDA VICE (MD)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:VICE
Last Name:HAYNIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEISH
Other - Last Name:VICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2225 LINE AVENUE
Mailing Address - Street 2:MID CITY PEDIATRICS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104
Mailing Address - Country:US
Mailing Address - Phone:318-221-2225
Mailing Address - Fax:318-459-2955
Practice Address - Street 1:2225 LINE AVENUE
Practice Address - Street 2:MID CITY PEDIATRICS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-221-2225
Practice Address - Fax:318-459-2955
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29920208000000X
LA301709208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics