Healthcare Provider Details

I. General information

NPI: 1629673272
Provider Name (Legal Business Name): LISA ANN HAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BOUNDBROOK DR
CENTERVILLE OH
45459-1836
US

IV. Provider business mailing address

34 BOUNDBROOK DR
CENTERVILLE OH
45459-1836
US

V. Phone/Fax

Practice location:
  • Phone: 937-668-1179
  • Fax:
Mailing address:
  • Phone: 937-668-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: