Provider Demographics
NPI:1811957905
Name:HAYNIE, LISA (CFNP)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:HAYNIE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ARENDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:114 EASTPOINTE CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7846
Mailing Address - Country:US
Mailing Address - Phone:601-856-1975
Mailing Address - Fax:
Practice Address - Street 1:1339 OAK PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-6804
Practice Address - Country:US
Practice Address - Phone:601-713-1642
Practice Address - Fax:601-981-6213
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR784342363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119447Medicaid
MS358537YJ5DMedicare PIN
MSS57514Medicare UPIN
MS00119447Medicaid