Healthcare Provider Details

I. General information

NPI: 1194646992
Provider Name (Legal Business Name): JUSTIN GUY HAINES PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 COMMERCIAL CT STE C
VENICE FL
34292-1642
US

IV. Provider business mailing address

425 COMMERCIAL CT STE C
VENICE FL
34292-1642
US

V. Phone/Fax

Practice location:
  • Phone: 941-244-4377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9395170
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11050711
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: