Healthcare Provider Details

I. General information

NPI: 1730466053
Provider Name (Legal Business Name): MICHELLE MOORE HAYNIE NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 E.BERT KOUNS INDUSTRIAL LOOP, NICU WEST WING
SHREVEPORT LA
71105
US

IV. Provider business mailing address

333 JOHNS BLUFF CIR
SHREVEPORT LA
71106-4733
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-4316
  • Fax:
Mailing address:
  • Phone: 318-426-5556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAP06220
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP06220
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAP130435
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberPA040129
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: