Basic Information
| Provider Information | |||||||||
| NPI: | 1548428790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYMAKER | ||||||||
| FirstName: | SHONDA | ||||||||
| MiddleName: | KAYE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 MARKET AVE. N. | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 MARKET AVE. N. | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934553 | ||||||||
| FaxNumber: | 3304933761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP09758 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | COA.09758-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 56106 | 05 | OH | MEDICAID |