Healthcare Provider Details

I. General information

NPI: 1821215641
Provider Name (Legal Business Name): AMANDA ERIN HAYNES D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ERIN BREHM D.O.

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE 19-30
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 570-214-1982
  • Fax:
Mailing address:
  • Phone: 858-554-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number20A800
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberOT011209
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberOS014610
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: