Provider Demographics
NPI:1396106530
Name:HAYNES MEDICAL CLINIC
Entity type:Organization
Organization Name:HAYNES MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAYNES WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC, FNP
Authorized Official - Phone:731-407-4922
Mailing Address - Street 1:1009 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4331
Mailing Address - Country:US
Mailing Address - Phone:731-407-4922
Mailing Address - Fax:731-407-4920
Practice Address - Street 1:1009 E WOOD ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4331
Practice Address - Country:US
Practice Address - Phone:731-407-4922
Practice Address - Fax:731-407-4920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350G8011Medicare PIN