Healthcare Provider Details

I. General information

NPI: 1083792949
Provider Name (Legal Business Name): THEADA C. HAYNES R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 MARION ST
COLUMBIA SC
29201-2113
US

IV. Provider business mailing address

3113 JACKSON CREEK RD
WINNSBORO SC
29180-7663
US

V. Phone/Fax

Practice location:
  • Phone: 803-898-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR59025
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: