Provider Demographics
NPI:1902208101
Name:HAYNES, MOLLY DEE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:DEE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:DEE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2012
Mailing Address - Country:US
Mailing Address - Phone:314-747-5800
Mailing Address - Fax:314-747-5866
Practice Address - Street 1:5000 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2012
Practice Address - Country:US
Practice Address - Phone:314-747-5800
Practice Address - Fax:314-747-5866
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily