=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326500125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ACHANTE HAYWOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2019
-----------------------------------------------------
Last Update Date | 04/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 W STATE ST STE 200
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-552-1882
-----------------------------------------------------
Fax | 419-616-0400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 NAPOLEON ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-280-6419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------