Provider Demographics
NPI:1730743014
Name:HAINES, DIALENE R (STNA)
Entity type:Individual
Prefix:MRS
First Name:DIALENE
Middle Name:R
Last Name:HAINES
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 WESTBROOK DR APT 110
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-1201
Mailing Address - Country:US
Mailing Address - Phone:216-777-9316
Mailing Address - Fax:
Practice Address - Street 1:4200 WESTBROOK DR APT 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-1201
Practice Address - Country:US
Practice Address - Phone:216-777-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402051890318171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH402051890318OtherSTNA