Provider Demographics
NPI:1619844800
Name:HAYNES, DEMETRIUS ANTWAN
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:ANTWAN
Last Name:HAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 TARAWA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2950
Mailing Address - Country:US
Mailing Address - Phone:646-717-7222
Mailing Address - Fax:
Practice Address - Street 1:203 TARAWA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2950
Practice Address - Country:US
Practice Address - Phone:646-717-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility