Provider Demographics
NPI:1336745652
Name:DOCTOR AMY HAYNES INC
Entity Type:Organization
Organization Name:DOCTOR AMY HAYNES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:406-721-2147
Mailing Address - Street 1:521 S 2ND ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-1832
Mailing Address - Country:US
Mailing Address - Phone:406-721-2147
Mailing Address - Fax:406-543-1020
Practice Address - Street 1:521 S 2ND ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1832
Practice Address - Country:US
Practice Address - Phone:406-721-2147
Practice Address - Fax:406-543-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871061630OtherINDIVIDUAL NPI DR. STEPHANIE RAVEN
MTAHC-NAT-LIC-1945OtherSTATE LICENSE DR RAVEN
14923677OtherCAQH DR. RAVEN