Healthcare Provider Details

I. General information

NPI: 1225519788
Provider Name (Legal Business Name): KELLI HAYNES RN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14801 S 108TH ST
SPRINGFIELD NE
68059-4925
US

IV. Provider business mailing address

14801 S 108TH ST
SPRINGFIELD NE
68059-4925
US

V. Phone/Fax

Practice location:
  • Phone: 140-233-9360
  • Fax:
Mailing address:
  • Phone: 402-339-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number59752
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: