Healthcare Provider Details

I. General information

NPI: 1952062259
Provider Name (Legal Business Name): ESTEFANIA HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 MISSION GORGE RD
SAN DIEGO CA
92120-3410
US

IV. Provider business mailing address

550 PARKSIDE DR
CHULA VISTA CA
91910-8506
US

V. Phone/Fax

Practice location:
  • Phone: 619-481-5219
  • Fax:
Mailing address:
  • Phone: 949-872-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: