Provider Demographics
NPI:1922005545
Name:HAYNES, SUSAN CRAIG (APN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CRAIG
Last Name:HAYNES
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:3215 STECK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7566
Mailing Address - Country:US
Mailing Address - Phone:512-476-3556
Mailing Address - Fax:512-476-0195
Practice Address - Street 1:3215 STECK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7566
Practice Address - Country:US
Practice Address - Phone:512-476-3556
Practice Address - Fax:512-476-0195
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX570847363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0928954-03Medicaid
TX0928954-03Medicaid
TXTXB107541Medicare PIN