Provider Demographics
NPI:1730466053
Name:HAYNIE, MICHELLE MOORE (NNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MOORE
Last Name:HAYNIE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 JOHNS BLUFF CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4733
Mailing Address - Country:US
Mailing Address - Phone:318-426-5556
Mailing Address - Fax:
Practice Address - Street 1:1453 E.BERT KOUNS INDUSTRIAL LOOP, NICU WEST WING
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-681-4316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06220363LN0000X, 363L00000X
TXAP130435363LN0000X
LAPA040129363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner