Basic Information
| Provider Information | |||||||||
| NPI: | 1831399484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
| FaxNumber: | 4194720838 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WOODVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434691209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5674824112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35090126 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2770078 | 05 | OH | MEDICAID |