Healthcare Provider Details

I. General information

NPI: 1659320232
Provider Name (Legal Business Name): LAUREN S HAYNIE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MICHIGAN AVE NE 108 DUFOUR CENTER
WASHINGTON DC
20064-0001
US

IV. Provider business mailing address

2349 HAZELWOOD CT
WALDORF MD
20601-4538
US

V. Phone/Fax

Practice location:
  • Phone: 202-319-6049
  • Fax: 202-319-4752
Mailing address:
  • Phone: 301-638-3097
  • Fax: 202-319-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1662
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: