Provider Demographics
NPI:1124274964
Name:HAYNES, MOLLY JANE (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:JANE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 SE 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1218
Mailing Address - Country:US
Mailing Address - Phone:503-239-3863
Mailing Address - Fax:
Practice Address - Street 1:7201 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5523
Practice Address - Country:US
Practice Address - Phone:503-286-6865
Practice Address - Fax:503-286-6881
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered