Healthcare Provider Details

I. General information

NPI: 1932239548
Provider Name (Legal Business Name): KATHEEN R. HAYNIE CMY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E COTATI AVE
COTATI CA
94931-4475
US

IV. Provider business mailing address

10310 MINNESOTA AVE
PENNGROVE CA
94951-9687
US

V. Phone/Fax

Practice location:
  • Phone: 707-665-9391
  • Fax:
Mailing address:
  • Phone: 707-665-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: