Healthcare Provider Details

I. General information

NPI: 1093069072
Provider Name (Legal Business Name): ANDREA SHANA HAYNES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

305 DONAN ST
MOUND CITY MO
64470-1601
US

V. Phone/Fax

Practice location:
  • Phone: 402-346-8800
  • Fax:
Mailing address:
  • Phone: 402-917-7411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2005038768
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR205129-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: