Healthcare Provider Details

I. General information

NPI: 1093049488
Provider Name (Legal Business Name): TABITHA LYNN HAYNES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST STE 102
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

3300 S FISKE BLVD STE 302
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-3455
  • Fax: 321-434-3456
Mailing address:
  • Phone: 321-434-3455
  • Fax: 321-434-3456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10118
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11004630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: