Provider Demographics
NPI:1255111746
Name:HAYNES, DANIELLE REVEE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:REVEE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8813 N TARRANT PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76182-8400
Mailing Address - Country:US
Mailing Address - Phone:678-999-3546
Mailing Address - Fax:
Practice Address - Street 1:8813 N TARRANT PKWY STE 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76182-8400
Practice Address - Country:US
Practice Address - Phone:678-999-3546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1951968335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier