Provider Demographics
NPI:1912256165
Name:HAYNES, HALEY GRACE
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:GRACE
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 1:4415 STATE ST
Mailing Address - Street 2:APT 3
Mailing Address - City:RIVERDALE
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6311
Mailing Address - Country:US
Mailing Address - Phone:563-340-6701
Mailing Address - Fax:
Practice Address - Street 1:4415 STATE ST
Practice Address - Street 2:APT 3
Practice Address - City:RIVERDALE
Practice Address - State:IA
Practice Address - Zip Code:52722-6311
Practice Address - Country:US
Practice Address - Phone:563-340-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005488225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant