Healthcare Provider Details

I. General information

NPI: 1346591815
Provider Name (Legal Business Name): CARISSA HAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 WYOMING ST
DAYTON OH
45409-2731
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-223-4461
  • Fax: 937-449-7603
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.13356-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP13356
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: