Healthcare Provider Details

I. General information

NPI: 1639470503
Provider Name (Legal Business Name): DEATOSHA DENISE HAYNES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VETERANS AVE
BILOXI MS
39531-2410
US

IV. Provider business mailing address

7722 PEMBROKE CIR
MOBILE AL
36695-4476
US

V. Phone/Fax

Practice location:
  • Phone: 228-523-5000
  • Fax:
Mailing address:
  • Phone: 251-635-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberAL 1-094279
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: