Provider Demographics
NPI:1912952417
Name:HAINES, KATHLEEN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:HAINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:WFAN-IMUS BLDG.
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1914
Mailing Address - Country:US
Mailing Address - Phone:551-996-5306
Mailing Address - Fax:201-996-9815
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:WFAN-IMUS BLDG.
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:551-996-5306
Practice Address - Fax:201-996-9815
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072899002080P0201X, 2080P0216X
NY1280132080P0201X, 2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF47880Medicare UPIN