Basic Information
Provider Information | |||||||||
NPI: | 1235304023 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAYNES | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | F.N.P | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTLER | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | F.N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 547 | ||||||||
Address2: |   | ||||||||
City: | LITTLE RIVER | ||||||||
State: | SC | ||||||||
PostalCode: | 295660547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436638000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3236 HOLMESTOWN RD | ||||||||
Address2: | SUITE E1 | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295887495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436638000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2008 | ||||||||
LastUpdateDate: | 04/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN122940 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4031 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 4031 | 01 | SC | SC STATE LICENSE | OTHER | RN122940 | 01 | GA | STATE LICENSE | OTHER | 7004853 | 05 | NC |   | MEDICAID | NP0413 | 05 | SC |   | MEDICAID |