Basic Information
Provider Information
NPI: 1003139478
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HAYNES
FirstName: STEPHANIE
MiddleName: LYNN
NamePrefix: MRS.
NameSuffix:  
Credential: P.T.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 116 SEAGRAPE DR
Address2:  
City: JACKSONVILLE BEACH
State: FL
PostalCode: 322502530
CountryCode: US
TelephoneNumber: 9042377198
FaxNumber: 9042418499
Practice Location
Address1: 1482 3RD ST S
Address2:  
City: JACKSONVILLE BEACH
State: FL
PostalCode: 322506310
CountryCode: US
TelephoneNumber: 9042463232
FaxNumber: 9042463626
Other Information
ProviderEnumerationDate: 03/12/2010
LastUpdateDate: 03/12/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT 18903FLY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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