MEDICARE: DANIELLE REVEE HAYNES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	1951968	TX

General Provider Information

NPI Number	:	1255111746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE REVEE HAYNES

Provider Business Mailing Address
First Line	:	8813 N TARRANT PKWY STE 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76182-8400
Country	:	US
Telephone Number	:	678-999-3546
Fax Number	:

Provider Business Practice Location Address
First Line	:	8813 N TARRANT PKWY STE 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76182-8400
Country	:	US
Telephone Number	:	678-999-3546
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2023
Last Update Date	:	10/02/2023

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