Provider Demographics
NPI:1053895474
Name:HAYNES, BRANDI MICHELLE (NP)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3631
Mailing Address - Country:US
Mailing Address - Phone:423-613-3300
Mailing Address - Fax:423-623-4088
Practice Address - Street 1:229 HEDRICK DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821
Practice Address - Country:US
Practice Address - Phone:423-623-1057
Practice Address - Fax:423-625-8620
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044334Medicaid