Provider Demographics
NPI:1720386808
Name:HAINES, VICKI MARIE
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:MARIE
Last Name:HAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9221 SANDIFUR PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9241
Mailing Address - Country:US
Mailing Address - Phone:509-233-7546
Mailing Address - Fax:509-795-3508
Practice Address - Street 1:9221 SANDIFUR PKWY STE A
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9241
Practice Address - Country:US
Practice Address - Phone:509-233-7546
Practice Address - Fax:509-795-3508
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60211812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMH2348022OtherDEA CERTIFICATION