Healthcare Provider Details

I. General information

NPI: 1174672455
Provider Name (Legal Business Name): DYNITA HAISLIP CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANTONSBURG RD PICU
GREENVILLE NC
27834-2818
US

IV. Provider business mailing address

2100 STANTONSBURG RD PICU
GREENVILLE NC
27834-2818
US

V. Phone/Fax

Practice location:
  • Phone: 252-847-4984
  • Fax: 252-847-4262
Mailing address:
  • Phone: 252-847-4984
  • Fax: 252-847-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number005001751
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: