Provider Demographics
NPI:1154550804
Name:HAYNES, LATRISA E (LPN)
Entity type:Individual
Prefix:
First Name:LATRISA
Middle Name:E
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 W FIEBRANTZ AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1507
Mailing Address - Country:US
Mailing Address - Phone:414-840-8393
Mailing Address - Fax:
Practice Address - Street 1:4407 W FIEBRANTZ AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1507
Practice Address - Country:US
Practice Address - Phone:414-840-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306436-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse