Provider Demographics
NPI:1023877305
Name:HAYNIE, NICHOLAS WAYNE (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WAYNE
Last Name:HAYNIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 N RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3721
Mailing Address - Country:US
Mailing Address - Phone:435-757-8128
Mailing Address - Fax:
Practice Address - Street 1:2555 UNIVERSITY BLVD.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45324
Practice Address - Country:US
Practice Address - Phone:937-775-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program