Provider Demographics
NPI:1437900222
Name:HAYNES, JUDITH LYNN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOLLAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1535
Mailing Address - Country:US
Mailing Address - Phone:810-305-1567
Mailing Address - Fax:
Practice Address - Street 1:1010 HOLLAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1535
Practice Address - Country:US
Practice Address - Phone:810-305-1567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MI9280454374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No374U00000XNursing Service Related ProvidersHome Health Aide