Basic Information
| Provider Information | |||||||||
| NPI: | 1003140195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYNES | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 675 SOUTH 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974242776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419141829 | ||||||||
| FaxNumber: | 5419429022 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 SOUTH 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974242776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419141829 | ||||||||
| FaxNumber: | 5419429022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 163W00000X | 095000628RN | OR | Y | Nursing Service Providers | Registered Nurse | 163WC1500X | 095000628RN | OR | N | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 500611115 | 05 | OR | MEDICAID |