Healthcare Provider Details

I. General information

NPI: 1649238411
Provider Name (Legal Business Name): ANITA LYNN HAYNES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 PHOENIX BLVD SUITE 100
ATLANTA GA
30349-5591
US

IV. Provider business mailing address

1745 PHOENIX BLVD SUITE 100
ATLANTA GA
30349-5591
US

V. Phone/Fax

Practice location:
  • Phone: 770-994-9326
  • Fax: 770-994-4747
Mailing address:
  • Phone: 770-994-9326
  • Fax: 770-994-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57638
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: