=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336745652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOCTOR AMY HAYNES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2020
-----------------------------------------------------
Last Update Date | 12/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 S 2ND ST W
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-721-2147
-----------------------------------------------------
Fax | 406-543-1020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 S 2ND ST W
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-721-2147
-----------------------------------------------------
Fax | 406-543-1020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NATUROPATHIC DOCTOR
-----------------------------------------------------
Name | STEPHANIE RAVEN
-----------------------------------------------------
Credential | ND
-----------------------------------------------------
Telephone | 406-721-2147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------