Provider Demographics
NPI:1851916845
Name:HAYNES, MARY J (CNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:HAYNES
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 W COUNTY ROAD 785 N
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-7536
Mailing Address - Country:US
Mailing Address - Phone:812-629-4021
Mailing Address - Fax:
Practice Address - Street 1:4384 W COUNTY ROAD 785 N
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-7536
Practice Address - Country:US
Practice Address - Phone:812-629-4021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN376K00000X
CN09300240376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty