Provider Demographics
NPI:1780064196
Name:HAYNES, ANISSA NICHELLE (ADMINISTARTOR)
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:NICHELLE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:ADMINISTARTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 HIGHWAY 59 LOOP N
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-5704
Mailing Address - Country:US
Mailing Address - Phone:936-252-2074
Mailing Address - Fax:
Practice Address - Street 1:801 HIGHWAY 59 LOOP N
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-5704
Practice Address - Country:US
Practice Address - Phone:936-252-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker