MEDICARE: CANDACE ANN HAYNES FNP-C

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	363LF0000X	Family Nurse Practitioner	83349	OK

General Provider Information

NPI Number	:	1407326622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDACE ANN HAYNES FNP-C

Provider Business Mailing Address
First Line	:	3515 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0711
Country	:	US
Telephone Number	:	903-791-9355
Fax Number	:	903-793-0496

Provider Business Practice Location Address
First Line	:	1701 S DOUGLAS BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6221
Country	:	US
Telephone Number	:	405-302-8999
Fax Number	:	405-733-9360

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

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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