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:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X095000628RNORY Nursing Service ProvidersRegistered Nurse 
163WC1500X095000628RNORN Nursing Service ProvidersRegistered NurseCommunity Health

ID Information
IDTypeStateIssuerDescription
50061111505OR MEDICAID


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