MEDICARE: SAVANNAH HAYNES STUDENT

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1265031736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAVANNAH HAYNES STUDENT

Provider Business Mailing Address
First Line	:	6 PALM RD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34996-6305
Country	:	US
Telephone Number	:	772-486-6114
Fax Number	:

Provider Business Practice Location Address
First Line	:	6 PALM RD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34996-6305
Country	:	US
Telephone Number	:	772-486-6114
Fax Number	:

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

Provider Enumeration Date	:	10/25/2020
Last Update Date	:	10/25/2020

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