Healthcare Provider Details

I. General information

NPI: 1629508783
Provider Name (Legal Business Name): REBECCA HAYNES CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ELLENBERGER CPNP

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PARKER DR
MONROE GA
30656-4747
US

IV. Provider business mailing address

297 COOPER RD
LOGANVILLE GA
30052-2518
US

V. Phone/Fax

Practice location:
  • Phone: 678-381-2630
  • Fax: 678-381-2627
Mailing address:
  • Phone: 783-812-6306
  • Fax: 678-381-2627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209240
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN-NP209240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: