MEDICARE: SHIWAN DANAE 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1972121655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIWAN DANAE HAYNES

Provider Business Mailing Address
First Line	:	2424 N DAVIDSON ST STE 110
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1882
Country	:	US
Telephone Number	:	704-412-1602
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 N DAVIDSON ST STE 110D
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1882
Country	:	US
Telephone Number	:	704-412-1602
Fax Number	:

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	08/31/2020

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Directions to “ SHIWAN DANAE HAYNES ” Practice Location

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