Healthcare Provider Details

I. General information

NPI: 1952705733
Provider Name (Legal Business Name): MISTY M HAYCRAFT CST,CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY M MARTIN

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAYFAIR DR STE 305
OWENSBORO KY
42301-4572
US

IV. Provider business mailing address

PO BOX 23329
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-2720
  • Fax: 270-688-2729
Mailing address:
  • Phone: 270-688-2720
  • Fax: 270-688-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number132002
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: