Provider Demographics
NPI:1902002900
Name:HAYNIE CLEARY, MARY JILL (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY JILL
Middle Name:
Last Name:HAYNIE CLEARY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:H
Other - Last Name:CLEARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ANP
Mailing Address - Street 1:109 BEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2085363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA05637189OtherMEDICARE ID
SCAA0563Medicare UPIN