Basic Information
| Provider Information | |||||||||
| NPI: | 1902208101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | DEE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OWENS | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | DEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5000 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147475800 | ||||||||
| FaxNumber: | 3147475866 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147475800 | ||||||||
| FaxNumber: | 3147475866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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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 | 2015024787 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.