Provider Demographics
NPI:1285176990
Name:HAYNIE, QUADE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:QUADE
Middle Name:
Last Name:HAYNIE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 E ALAMOS AVE
Mailing Address - Street 2:UNIT #105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-1463
Mailing Address - Country:US
Mailing Address - Phone:435-421-9132
Mailing Address - Fax:
Practice Address - Street 1:1717 S CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-4709
Practice Address - Country:US
Practice Address - Phone:435-421-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT68882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer