Basic Information
| Provider Information | |||||||||
| NPI: | 1134115546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAIMES | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2355 W 136TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800239331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165346484 | ||||||||
| FaxNumber: | 9373822111 | ||||||||
| Practice Location | |||||||||
| Address1: | 2355 W 136TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800239331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036589827 | ||||||||
| FaxNumber: | 3036589828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP05099 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2496464 | 05 | OH | MEDICAID |