Provider Demographics
NPI:1538805866
Name:HAYNES, DEJAH DOMINIQUE
Entity type:Individual
Prefix:
First Name:DEJAH
Middle Name:DOMINIQUE
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 1:160 CLAIREMONT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2546
Mailing Address - Country:US
Mailing Address - Phone:516-421-2555
Mailing Address - Fax:
Practice Address - Street 1:2591 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-6502
Practice Address - Country:US
Practice Address - Phone:678-209-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA099114164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA222118476048Medicaid