Provider Demographics
NPI:1699141804
Name:HAYNES, STEFANIE R
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:R
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:R
Other - Last Name:ANDRISKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:774-221-5136
Practice Address - Street 1:460 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2442
Practice Address - Country:US
Practice Address - Phone:774-221-5135
Practice Address - Fax:774-221-5136
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266318363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily