Provider Demographics
NPI:1720536766
Name:HAYES, WENDY (PP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:HAYES
Suffix:
Gender:F
Credentials:PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:DOERUN
Mailing Address - State:GA
Mailing Address - Zip Code:31744-0612
Mailing Address - Country:US
Mailing Address - Phone:229-454-0992
Mailing Address - Fax:
Practice Address - Street 1:922 S FAIN ST
Practice Address - Street 2:
Practice Address - City:DOERUN
Practice Address - State:GA
Practice Address - Zip Code:31744-5010
Practice Address - Country:US
Practice Address - Phone:229-454-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16-0026171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor